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The Midults: I slept with my male best friend – but I don't fancy him
The Midults: I slept with my male best friend – but I don't fancy him

Telegraph

time25-05-2025

  • General
  • Telegraph

The Midults: I slept with my male best friend – but I don't fancy him

Dear A&E, I slept with my best male friend (we were a bit drunk) and it was a terrible idea because I do not actually fancy him but he has brought up 'giving it a go' with me. Then I slept with him again because the sex is really, really great (the best I've ever had) even though I still don't fancy him – which is weird. I know it's a stupid idea to keep getting a bit drunk and having sex with him but I'm finding it hard to resist and I feel guilty and confused about how to navigate this. I truly love him and don't want to hurt him or lose him. – Licentious Dear Licentious, Interesting times, your end. Gosh, our 20s can be wilderness years, can't they? Some seem miraculously able to get themselves sorted romantically, financially, emotionally with little fuss, while others of us (no less kind or capable) flail about, wrecking everything and – hopefully – learning about ourselves and other human beings along the way. There are, to us, two stand-out phrases in your letter (edited above): ' the best sex I've ever had ' and 'I truly love him'. Then there's the self-confessed weirdness of the situation: 'I still don't fancy him'. No wonder you are confused. And he is not some random bloke, so there is jeopardy (and, perhaps, promise) woven through the fabric of your conundrum. You say you don't fancy him. Maybe this is worth examining more deeply because, even though you don't fancy him in theory, it seems that you do in practice. We can get stuck in our attitudes towards people and we would often do well to take pause and re-assess because we change. They change. The world changes. This has thrown up an opportunity – a necessity, really – for you to check in with yourself regarding what this relationship means to you; its limitations and its potentialities. As you get older it can get harder to know if you desire someone when you first meet them and, sometimes, if you have an overwhelming sexual response to a person it can prove to be a warning sign. A blazing sex fire that ignites within you the moment a person walks into the room is not necessarily a sign that you are meant to be with them. Odd and counterintuitive and annoying though that can be. And so we develop a kind of suck-it-and see litmus test. We date. We like them. We test drive. We test drive a few more times. And then we have more information regarding the connection and we decide whether we meaningfully step into that story. Well, Licentious, you got a bit tipsy and put your floor through the floor and found a few things out along the way, didn't you? You have fantastic sex with him. And fantastic sex tends to be about more than technique and friction. It tends to be about connection. You truly love him. This has the ingredients for something that could be quite big. But also quite sad. Should it go wrong. Why don't you fancy him? Is there something that really repulses you or is that just a decision that you made way back when? Is he, somehow, not what you thought you'd date. Is he taller, shorter, geekier, artier, more-reserved, less confident than the boyfriend template you held in your mind's eye? Is it that he's incredibly nice to you and available which makes him less interesting? Have a word with yourself and take this seriously. We do not want you flouncing off into the wide blue yonder, only to realise, latterly, that you have broken your own heart. You don't want to risk hurting him or losing him. You are quite far down the line with this risk already. 'No strings' is not an option. There are strings. There is a whole cobweb of shared history and friendship and camaraderie. Pretending that none of this has happened won't work. Continuing to sleep with him while pretending it doesn't mean anything won't work. In short, pretending won't work. This has relationship written all over it. It also has disaster written all over it. But that is the nature of human interaction. Run the calculations. Ask yourself how you would feel if he announced, tomorrow, that he had met someone. Consider your options. Do not open this up to your friendship group and make a decision by committee. You are entitled to a private life. And, if you decide that you do not fancy him and cannot take this further, talk to him. Tell him you love him too much to risk your friendship. Or that you do not feel you can 'give it a go' at this point in your life. And this probably means that you cannot have a drink anywhere near him and should put a warning by his name, on your phone, saying 'do NOT message.' Because good sex has a narcotic quality that makes it hard to resist. Or you go gently forwards with this. Quietly and honestly. Whichever path you choose, make sure he is fully aware of where you stand at all times. The greatest risk is a betrayal of trust. You may feel as though you have all the power but that will not be the case forever. By treating him with the utmost respect you will simultaneously be respecting yourself and laying down a blueprint for the way you conduct yourself in this world. And that has huge value.

A 26-Year-Old With Abnormal Eye Movement and Agitated Delirium
A 26-Year-Old With Abnormal Eye Movement and Agitated Delirium

Medscape

time07-05-2025

  • Health
  • Medscape

A 26-Year-Old With Abnormal Eye Movement and Agitated Delirium

Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians, but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please email us at ccsuggestions@ with the subject line "Case Challenge Suggestion." We look forward to hearing from you. Background A 26-year-old woman presents to the emergency department (ED) with confusion, agitation, sweating, and abnormal involuntary eye movement (diaphoresis and ocular clonus). The symptoms started the previous week; they were mild at first, and the patient attributed them to a week-long heat wave in the city. The patient felt worse as the week went on and decided to come to the ED because she was not feeling better that morning. She started sweating profusely in the middle of the night, felt her leg muscles become stiff, and was increasingly nauseous. Her fiancé insisted she go to the ED as early as possible because she seemed agitated and confused, pacing around the apartment instead of taking a shower. The patient's history is reviewed with her fiancé. She has a history of depression, for which she takes fluoxetine; her dose was increased by her psychiatrist 1 month ago. For migraines, she takes sumatriptan and ondansetron. Because her headaches have recently worsened, her neurologist started her on tramadol. She also has had a cough, for which she self-medicated with dextromethorphan. The remainder of her medical history is noncontributory. She does not smoke, denies drug or alcohol use, and has no allergies or family history of other significant illness. Physical Examination and Workup Upon physical examination, her blood pressure is 165/105 mm Hg, pulse 128 beats/min, respiratory rate 20 breaths/min, pulse oximetry 98% on room air, and temperature 100.6°F (38.1°C). The patient is a thin woman who seems agitated and restless but complies with the examination. The lung examination reveals clear breath sounds in all fields. Her heart has a regular rhythm, and no murmur is appreciated. Upon neurologic evaluation, she is alert and oriented to date but not to time or place. Her speech is clear and fluent, with good repetition, comprehension, and naming. She recalls 1 out of 3 objects at 5 minutes. No tenderness or signs of trauma are found over the scalp and neck. No proptosis, lid swelling, conjunctival injection, or chemosis is observed. The patient is able to identify a pen and a clock. She can count fingers and has an intact bitemporal visual field. Extraocular muscles are intact upon examination; she is able to look from right to left as well as up and down. Spontaneous right ocular clonus is observed. Her pupils are 2 mm and are reactive to light. Sensory examination of her face is unremarkable. Her tongue and uvula are midline, with a positive gag reflex. Her hearing test findings are symmetric. Shoulder-shrug findings are equal on both sides. Strength is 5/5 in the upper and lower extremities. Sensory examination findings reveal symmetry to light touch, pinprick, temperature, vibration, and proprioception. The patient's reflexes are 2+, except in the lower extremities, where bilateral hyperreflexia is observed. She is able to perform rapid alternating movements. The remainder of her physical examination findings are unremarkable. An ECG reveals normal sinus at a rate of 128 beats/min, without ST-T wave changes. Head CT is performed, and an example similar to the findings in this case is shown below (Figure 1). Figure 1. A urine pregnancy test result is negative. Laboratory analyses performed in the ED include a CBC count, metabolic panel, hepatic panel with lipase, and troponin level. Laboratory test findings are remarkable for a WBC count of 12.4 × 103 cells/µL (reference range, 4.2-11.0 × 103 cells/µL), with 69% segmented neutrophils (54%-62%) and bandemia of 2% (3%-5%), and a hemoglobin level of 11.6 g/dL (reference range for women, 12-15 g/dL). Her troponin level is 0.5 ng/mL (reference range, 0-0.4 ng/mL). The remainder of laboratory test findings, including a toxicology screen and creatine phosphokinase level, were within normal limits. Interpretation of the CT scan was normal. The patient was given acetaminophen for the low-grade fever. Intravenous fluids were started, and she was admitted to the medicine floor. Discussion Serotonin syndrome is a potentially life-threatening condition that occurs secondary to serotonin toxicity in the central and peripheral nervous systems. This can be due to a combination of serotonergic agents, an increase in therapeutic dosing of a serotonergic agent, and an overdose or inadvertent interactions of serotonergic agents. Serotonin syndrome is a clinical diagnosis; therefore, a careful and thorough history and physical and neurologic examinations are essential, as is a high level of suspicion.[1] Serotonin syndrome results from excessive stimulation or agonist activity at postsynaptic serotonin receptors; most often implicated is excessive binding at the serotonin 2A (5-HT 2A ) and serotonin 1A (5-HT 1A ) receptor subtypes. Those two subtypes may be the predominant cause of symptoms.[2] Presenting symptoms can vary widely and range from mild to life-threatening. Serotonin is produced in the neurons from L-tryptophan, and its concentration is regulated through feedback loops controlling its reuptake and metabolism. Serotonin receptors in the central nervous system regulate attention, behavior, temperature, the sleep/wake cycle, appetite, and muscle tone.[3] Serotonin receptors are also located in the peripheral nervous system; peripheral serotonin is produced by intestinal enterochromaffin cells and is involved in the regulation of gastrointestinal motility, uterine contraction, bronchoconstriction, and vascular tone. In addition, serotonin in platelets promotes their aggregation. No specific laboratory test is indicated to diagnose serotonin syndrome, and serotonin levels do not correlate with the severity of symptoms. The Hunter criteria are the most accurate diagnostic set available to diagnose serotonin syndrome, with 84% sensitivity and 97% specificity. The criteria require that a patient be taking a serotonergic agent and meet at least one of the following conditions[4]: Spontaneous clonus Inducible clonus with agitation or diaphoresis Ocular clonus with agitation or diaphoresis Tremor and hyperreflexia Hypertonia, temperature > 100.4°F (38°C), and ocular or inducible clonus A thorough history and physical and neurologic examinations are essential for diagnosis because no specific laboratory test is indicated to diagnose serotonin syndrome. Notably, serotonin levels do not correlate with the severity of symptoms. The Hunter criteria, as outlined previously, are the most accurate diagnostic set available to diagnose serotonin syndrome, with 84% sensitivity and 97% specificity, and the qualifying criteria are independent of one another, not concurrent. Differential Diagnoses Besides serotonin syndrome, other differential diagnoses were considered but excluded in this case. Neuroleptic malignant syndrome (NMS) is an idiopathic drug reaction to antipsychotics that has a presentation similar to that of serotonin syndrome; however, NMS presents with bradyreflexia, hyperpyrexia, and lead-pipe rigidity.[5] Myoclonus is rarely seen with NMS, and symptoms typically resolve in days, compared with 24 hours after removal of the offending agent in serotonin syndrome.[6] In addition, patients with NMS have a history of taking a neuroleptic agent (eg, haloperidol, chlorpromazine), atypical antipsychotics, or antiemetic drugs. Vital signs in persons with NMS typically are similar to those in persons with serotonin syndrome and can include hyperthermia, tachycardia, tachypnea, and hypertension.[5] For NMS, dantrolene is the most effective, evidence-based drug treatment available,[6] whereas no evidence-based drug treatments are available for serotonin syndrome. Malignant hyperthermia is a disorder of skeletal muscle that results from inhalation of halogenated anesthetics (eg, halothane, sevoflurane, desflurane, isoflurane), administration of depolarizing muscle relaxants (eg, succinylcholine), or stressors (eg, vigorous exercise, heat exposure).[7] Malignant hyperthermia is considered a hypermetabolic response of skeletal muscles, and affected patients may present with hyperthermia, tachycardia, tachypnea, increased carbon dioxide production or oxygen consumption, acidosis, hyperkalemia, muscle rigidity, and rhabdomyolysis. Malignant hyperthermia is treated with dantrolene, a specific antagonist that should be available wherever general anesthesia is administered. Anticholinergic toxicity results from an overdose with an anticholinergic agent and may present with hyperthermia, agitation, altered mental status, mydriasis, dry mucous membranes, urinary retention, and decreased bowel sounds.[8] Patients have normal muscular tone and reflexes in anticholinergic poisoning, compared with serotonin syndrome; the treatment is physostigmine. Patients with meningitis often have a history of headache, photophobia, neck stiffness, vomiting, and diplopia; they may also present with convulsions, abnormal movements, and/or posturing. Serotonin syndrome may be distinguished from other causes of agitated delirium on the basis of neuromuscular findings. Patients with sympathomimetic toxicity or infections of the central nervous system typically lack these findings. All the differential diagnoses mentioned can be associated with significant morbidity and mortality without prompt and appropriate treatment; therefore, differentiation based on clinical findings and a high index of suspicion is imperative. DDx Case Study A 30-year-old man presents with a 7-month history of worsening hallucinations and delusions. Management initiated by his psychiatrist 1 month ago included risperidone, lithium, olanzapine, and lorazepam. He was brought to the ED because he had been in bed for 3 days in a row and was feeling sluggish, with a temperature of 106°F (41.1°C). Upon examination, the patient is arousable but not oriented to date, time, or place. All extremities are rigid, and reflexes are decreased. His heart rate is 110 beats/min, respiratory rate is 24 breaths/min, and blood pressure is 130/80 mm Hg. No history of illicit drug use is reported. NMS is an idiopathic drug reaction to antipsychotics that has a presentation similar to that of serotonin syndrome and is characterized by bradyreflexia, hyperpyrexia, and lead-pipe rigidity. Symptoms typically resolve in days compared with 24 hours after removal of offending agent in serotonin syndrome. Patients with NMS have a history of taking a neuroleptic agent (eg, haloperidol, chlorpromazine), atypical antipsychotics, or antiemetic drugs. For NMS, dantrolene is the most effective, evidence-based drug treatment available. Medications Most Commonly Involved The medications most commonly involved in serotonin syndrome include selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), opioids, cough medications (eg, dextromethorphan), and antibiotics.[9] Specific drugs that have the potential to cause serotonin syndrome are as follows[1,6-12]: SSRIs Citalopram Fluoxetine Fluvoxamine Olanzapine/fluoxetine Paroxetine SNRIs Duloxetine Sibutramine Venlafaxine Triptans Almotriptan Eletriptan Frovatriptan Naratriptan Rizatriptan Sumatriptan Zolmitriptan Miscellaneous Buspirone Carbamazepine Cocaine Cyclobenzaprine Dextromethorphan Ergot alkaloids Fentanyl 5-Hydroxytryptophan Linezolid Lithium L-Tryptophan Meperidine Methadone Methamphetamine Methylene blue Metoclopramide Mirtazapine Ondansetron Phenelzine Selegiline St John's wort Tramadol Tranylcypromine Trazodone Tricyclic antidepressants Valproic acid Avoid prescribing the following opioids, because they precipitate or worsen serotonin syndrome in patients already receiving SSRIs or MAOIs: Tramadol Methadone Meperidine Fentanyl Opioids that have not been linked to serotonin syndrome include morphine, codeine, and hydrocodone; these should be administered if no alternative is available.[10] SSRIs, SNRIs, MAOIs, certain opioids (eg, fentanyl, tramadol), cough medications (eg, dextromethorphan), and antibiotics are the medication types most commonly involved in serotonin syndrome. Agitation and tremors associated with serotonin syndrome can be treated with benzodiazepines, which are nonspecific serotonin antagonists. Treatment Most cases of serotonin syndrome are mild and can be treated by withdrawal of the offending agent and supportive care, with complete resolution of the presenting symptoms.[1] Most cases of serotonin syndrome present for care within 6-24 hours of symptom onset and resolve within the following 24 hours. Agitation and tremors can be treated with benzodiazepines (which are nonspecific serotonin antagonists); however, in severe cases, patients may require neuromuscular paralysis, sedation, or intubation. Hyperthermia > 106°F (41.1°C) usually is associated with a poor prognosis. Patients presenting with hyperthermia and severe muscle rigidity should be managed with antipyretics, neuromuscular paralysis, sedation, or intubation as indicated.[11] Serotonin syndrome may be complicated by rhabdomyolysis, disseminated intravascular coagulation (DIC), hepatic or renal dysfunction, and lactic acidosis. Therefore, obtaining urinalysis, renal and hepatic function measurement, and a DIC profile should be part of management. Elicit from the patient a confirmation or denial of illicit or recreational drug use, especially in cases of intentional overdose, because this may complicate the clinical picture and delay diagnosis. Cyproheptadine is the recognized therapy for serotonin syndrome. Cyproheptadine is a histamine-1 receptor antagonist with anticholinergic and antiserotonergic properties. It is taken orally, and the initial dose is 4-12 mg, repeated every 2 hours, and discontinued if the maximum dose of 32 mg is reached without symptom improvement.[12] Serotonin syndrome resolves over time if promptly diagnosed and appropriately managed, highlighting the importance of a timely and accurate diagnosis. Polypharmacy also increases the risk for serotonin syndrome; therefore, reconciling a patient's medications is important if serotonin syndrome is suspected. Remember that medications such as fluoxetine have a long half-life and may require 5-8 weeks to be cleared from the system; thus, additional serotonergic medications should be cautiously added. Cyproheptadine is the recognized therapy for serotonin syndrome, given at an initial dose of 4-12 mg, repeated every 2 hours, not to exceed 32 mg. Physostigmine is the first-line treatment option for anticholinergic toxicity. Serotonin syndrome typically resolves within 24 hours of a patient presenting for care. Typical cases of serotonin syndrome are mild and can be treated by withdrawal of the offending agent and supportive care; neuromuscular paralysis, sedation, or intubation may be considered in severe cases with severe muscle rigidity and hyperthermia. The patient in this case was successfully managed by discontinuing the inciting agents and was treated with cyproheptadine and supportive care. After complete resolution of all symptoms, the patient was discharged (2 days after admission). Historical Footnote Although serotonin syndrome is rare, the case of Libby Zion in 1984 was instrumental in influencing and changing medicine in an unprecedented way. Zion was a patient who had been taking phenelzine, an antidepressant.[13] The therapeutic effects of phenelzine may continue for as long as 2 weeks after discontinuation. Zion was given meperidine for agitation, which led to deadly manifestations of serotonin syndrome. That case led to reforms in the grueling hours of medical residents across the United States.

Social Security Overpayment: The Repayment Rule Changes Once Again
Social Security Overpayment: The Repayment Rule Changes Once Again

CNET

time06-05-2025

  • Business
  • CNET

Social Security Overpayment: The Repayment Rule Changes Once Again

Did you get an extra-large Social Security check? Are you wondering if you'll need to pay it back? The answer is, maybe. Getty Images/CNET If you receive more money than expected from your Social Security payment, don't assume it's a gift from the Social Security Administration. More than likely, you received an overpayment due to changes in your account that either weren't reported on time or to another mistake by the SSA itself. You will have to repay the overpayment amount. It's understandable if you're confused about what's happening – there have been some back-and-forth changes. At first, the Social Security Administration rolled back rules so that if an overpayment occurred, it would withhold 100% of your payments until the overpayment was returned -- a full walkback from previous measures designed to ease the repayment timing for beneficiaries. Now those rules are changing again, and for the better. Below, we'll go over why overpayments happen and what the updated rules are if you receive one. For more, don't miss the Social Security payment schedule and how to apply for Social Security Retirement benefits. How do Social Security overpayments even happen? Social Security overpayments can happen in a few ways. If you start a new job while receiving benefits and report it to the administration, your monthly benefit check could be reduced -- and if you make over the yearly earnings limit, you may not get a check at all for that month. But if you got a job and didn't notify the administration about it, you may receive an overpayment. Another way overpayments could happen is if you've filed an appeal and are still receiving payments. More on appeals below. In other cases, overpayments are simply an error on the SSA's part. The SSA issues "Emergency Message" to staff about overpayments In March 2024, the SSA changed the amount taken from Social Security payments if an overpayment occurred – instead of withholding 100% of your next payment, it would withhold only 10%. This not only gave recipients more time to pay back the overpayment, but it eased the potential devastating financial consequences if your benefits payment was your only source of income. However, in March of this year, those rules were erased (including the announcement of the updates) and the old policy was reinstated: retain 100% of a recipient's benefit payment until the overpayment was returned. The updated policy went into effect on March 27. That's all changed yet again, with the SSA backing down on withholding 100% of a recipient's benefit payment. In an "Emergency Message" to staff late last month, the SSA announced that it would be changing the withholding percentages for individuals receiving Title II benefits (Retirement, Disability, or Survivors). Instead of retaining 100% of a payment, the SSA will now only withhold 50% until the overpayment is paid back. While this is certainly an improvement, the impact could still wreak havoc on beneficiaries financially. There's one other wrinkle to be aware of: If you receive an overpayment, when the Administration sees the error it will send a formal notice for the overpayment. Beneficiaries have 90 days to contact the SSA to either request a lower withholding rate, reconsideration, or a waiver. If contact isn't made within this time, the 50% withholding will go into effect. These changes went into effect as of April 25. Meanwhile, individuals receiving Supplemental Security Income will still only have 10% of their payments reduced when an overpayment occurs. How do I request a waiver for a Social Security overpayment? If you've been overpaid by over $1,000 and you don't believe you should have to repay the overage -- either because you don't think it's your fault or do not have the ability to repay it -- you can request a waiver. There's no time limit as to when you were overpaid and when you need to request a waiver -- you'll just need to show that the overpayment wasn't your fault or it would create a financial hardship for you. To request a waiver for a payment over $1,000, fill out a SSA-632 form and either mail it or drop it off at a local Social Security office. If you were overpaid less than $1,000 and you believe you were not at fault for it, you can request a waiver by calling 1-800-772-1213 or by visiting your local Social Security office to have the request processed over the phone or in person. When to file an appeal vs. when to request a waiver for overpayments If you don't believe you were overpaid, or if you receive a notice and you think the amount is incorrect, you can file an appeal. Unlike requesting a waiver, an appeal has a time limit for when you can file: You have 60 days from when you originally received the overpayment notice. Before you can file an appeal, you'll need to have a few things ready. This will include the overpayment notice you received, along with any legal forms, documents or written statements you have related to the situation. If you have a personal appointed representative, have their contact information handy. To file an appeal, head to the Non-Medical Appeal page on the SSA website, and click Start an Appeal and go through the steps. For more, don't miss the reports that the SSA is harder to contact after the February 2025 layoffs.

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