Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
Hypogonadism is Surprisingly Common in Middle-Aged Men
Defining hypogonadism (HGO) remains a remarkably difficult challenge. The 'normal' range for testosterone (TES) in adult males is typically 350-1050 ng/dL. This broad range compounds our uncertainty in addressing a man with borderline TES, since even though a man may register a normal TES level of 350 ng/dL, perhaps his 'normal' level three years previous was 650 ng/dL: hence, the current level is a dramatic reduction compared to prior levels. Additionally, as men age, it is commonplace to develop more subcutaneous fat, resulting in increased levels of sex hormone binding globulin (SHBG), which leads to decreased levels of free TES, the component of TES that ultimately is the active portion.
Primary care practices throughout the United States (n = 130) invited men aged 45 years and older to have their testosterone (total, free, and bioavailable) measured. Patients were not selected on the basis of any symptoms referable to TES status; rather, patients could be visiting for any medical reason. The mean age of the subjects (n = 2,162) was 61 years.
Excluding men who were already known to be hypogonadal, more than one third of unselected men aged 45 years and older met criteria for HGO There remain some uncertainties about the long-term risk-to-benefit ratio of TES replacement, but because HGO is associated with decreased bone mass and decrements in quality of life, when HGO is discovered, treatment should be considered.
Mulligan T, et al. Int J Clin Pract 2006;60:762-769.
Carpal Tunnel Syndrome: Capturing the Benefits of MultiModal Treatment
Numerous interventions for carpal tunnel syndrome (CTS) provide relief for some patients, but no single intervention appears routinely effective for all sufferers. Surgical intervention, even though usually beneficial when more conservative treatments are insufficient, is associated with failure or complications in up to 19% of patients.
Most clinicians and patients alike would prefer to treat CTS conservatively whenever feasible. Although individual treatment methodologies may provide symptom control, there is less literature on the success rate of combined therapies.
Thirty six young women with bilateral CTS (confirmed electrophysiologically) were randomly assigned to receive either splinting (SPL) + exercise (EXR), SPL + ultrasound (ULT), or all three interventions (SPL + EXR + ULT). All study subjects received treatment for 3 weeks, and were followed up 8 weeks post-treatment.
All treatment arms provided similar degrees of symptomatic improvement, which persisted at the 8-week post-treatment measurement. Because patient satisfaction scores for the SPL + EXR + ULT were superior to other groups, it may be the preferred intervention when available.
Baysal O, et al. Int J Clin Pract. 2006;60:820-828.
Diastolic Dysfunction: Not So Benign
The original models of chronic heart failure (CHF) simplistically viewed the problem as 'inadequate pumping,' manifest as a decreased ejection fraction. With wider availability of ECHO-cardiography it became clear that many patients with prototypic signs and symptoms CHF had normal ejection fractions. Soon it became evident that poor filling (diastolic dysfunction) can result in clinical syndromes which are indistinguishable from poor contractile function (systolic dysfunction). An EF (ejection fraction) < 40% is consistent with systolic dysfunction.
Mortality from CHF is substantial, surpassing the mortality rates of many of the most common cancers in America, prompting some to label CHF the 'hemodynamic malignancy.' Some data have suggested that diastolic dysfunction (DDF) has a more benign prognosis than systolic dysfunction (SDF).
Over a two-year period, CHF patients hospitalized in Ontario, Canada (n = 2,802) for whom data on ejection fraction were available, were followed for the outcomes of mortality within one year and hospital readmission (for CHF). Outcomes for persons with SDF and DDF were compared. Both the mortality at 1 year (22% vs 26%; P =NS) and the rate of CHF readmission were similar between the two groups. Although past data have suggested a more benign outcome for DDF than SDF, this robust study indicates similar outcomes for either mechanism of heart failure.
Bhatia RS, et al. N Engl J Med. 2006;355:260-269.
Defining hypogonadism (HGO) remains a remarkably difficult challenge. The 'normal' range for testosterone (TES) in adult males is typically 350-1050 ng/dL.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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