Folate and Mecobalamin on Hip Fx in Stroke Patients
Source: Sato Y, et al. JAMA. 2005;293:1082-1088.
Hip fractures (HIP) occur 2-4 times more commonly in persons who have sustained a stroke than an age-matched population. Amongst these individuals, fractures occur more commonly on the same side as the stroke; bone mineral density (BMD) studies have shown a corresponding decline in BMD on the paretic side, compared with the non-involved side.
Homocysteine levels have been associated with risk for ischemic stroke; indirect evidence indicates that elevated homocysteine levels may also be related to osteoporosis, since individuals with homocysteinuria (and concomitant marked elevations in homocysteine) demonstrate increased osteoporosis. Whether modulation of homocysteine by means of folate and B12 administration might effect HIP was the clinical question posed by this study.
Patients (n = 628) who had suffered an ischemic stroke resulting in hemiplegia at least 1 year prior to enrollment and were aged 65 or older were randomized in a double-blind fashion to folate and B12 vs placebo. Subjects were followed for 2 years.
The baseline homocysteine level was elevated in both groups. Folate/B12 supplementation resulted in a 38% decline in plasma homocysteine (compared with a 31% increase in the control group), and was associated with a dramatic 80% risk reduction in hip fractures (10 fractures in the treatment group, 43 in the placebo group)! No adverse effects of folate/B12 were identified. This is the first such study to demonstrate these highly favorable results, but many clinicians may be sufficiently impressed with the efficacy (combined with safety) that they consider inclusion of folate and B12 for persons who have suffered a hemiplegic ischemic stroke.
Accuracy of Clinical BP Measurement?
Source: Sala C, et al. Am J Hypertens. 2005;18:244-248.
Benefits accrued as a result of hypertension (HTN) treatment are based upon results of large, randomized, clinical trials, some of which do not provide thorough details about the method in which blood pressure (BP) was measured. Such issues as posture, timing, and time in repose have been reported to influence BP, but there are little data that specifically addresses variation in BP based upon these parameters obtained from a large population.
Sala and colleagues selected 540 consecutive male and female patients with essential HTN who were attending an Italian hospital clinic for a routine visit. BP was measured as follows: 1) seated in a chair, after 5-10 minutes had elapsed during history taking, with the arm supported on a desk at mid-sternum level, feet on the floor; 2) supine, after 5 minutes, at the end of the visit; 3) seated on the side of a bed for 3-5 minutes with the back unsupported, arm supported by the operator at mid-sternum level, feet on a foot stool; and 4) after standing for 3-5 minutes. A mercury-based sphygmomanometer was used.
Mean BP was statistically significantly lower when chair-seated (143.5/87.2) than BP measured supine (153.4/89.7), sitting on a bed (148.9/90.9), or standing (144.8/91.7). Other methods of measurement may produce meaningful deviations from BP that would be obtained using the guidelines recommended methodology.
Sexual Problems Among Women and Men Aged 40-80
Source: Laumann EO, et al. Int J Impot Res. 2005;17:39-57.
The Global Study of Sexual Attitudes and Behaviors is a database of 13,882 women and 13,618 men from 29 countries. Data were obtained in a variety of methods, including in-person or telephone interview (Westernized nations) or mail-in questionnaire (Middle-East, some countries in Asia, Africa). The population includes adults aged 40-80, regardless of marital status or gender orientation.
Worldwide, sexual problems were most frequent in Eastern and Southeast Asia. The most common problem for women was lack of interest in sex (ranging from 26-43% among different nations), followed by inability to reach orgasm (range, 18-41%). Amongst men, premature ejaculation was the most common difficulty (12.4% in the Middle East, 30.5% in Southeast Asia). Erectile dysfunction was next most common in men, with similar prevalence of lubrication difficulties in women.
Financial problems and depression were consistently associated with sexual dysfunction in women. Erectile dysfunction was associated with lower educational achievement.
Sexual dysfunction is commonplace in American men and women; this global vantage point provides a perspective about the worldwide burden of sexual dysfunction.
Morphine, Gabapentin for Neuropathic Pain
Source: Gilron I, et al. N Engl J Med. 2005;352:1324-1334.
The management of neuropathic pain (NPP) presents a challenge to clinicians of all specialties, since disorders associated with NPP span the gamut of medical disciplines. Opioid analgesics such as morphine (MOR) and gabapentin (GBPT) are 2 of the agents commonly used to manage NPP from diverse etiologies, although adverse effects or a ceiling dose for efficacy ultimately limit successful pain control in some patients. In several pharmacologic scenarios, it has been feasible to capitalize upon the beneficial effects of different classes of medications by using modest doses of complementary (ie, having potentially additive positive effects) agents, thereby minimizing their respective adverse effect profiles, without approaching their inherent therapeutic ceiling.
This randomized, double-blind trial assessed patients with NPP (n = 57) who were randomized to 5-week crossover periods of MOR (specifically, sustained release morphine), GBPT, GBPT + MOR, or active placebo (ie, lorazepam). The primary outcome was mean daily pain intensity. Baseline pain intensity was 5.72 on a 0-10 scale. The mean pain at 4-weeks treatment was statistically significantly different from placebo and baseline in persons treated with GBPT (pain = 4.15), MOR (pain = 3.7), and GBP + MOR (pain = 3.06). Lower doses of GBPT and MOR were required in combination to achieve a similar or superior therapeutic effect than the maximum dose of either single agent alone. Adverse effects of combination therapy were similar to those of monotherapy with MOR, although dry mouth with GBPT + MOR was considerably more frequent than either GBPT or MOR alone.
Correlation of Decreased Androgen Levels with Female Sexual Function Index
Source: Turna B, et al. Int J Impot Res. 2005;17:148-153.
Low libido (LLB) is one of the most distressing female sexual dysfunctions, and is the most commonly reported female sexual dysfunction in epidemiologic surveys. Studies with androgen replacement or supplementation have suggested that amplification of androgens has an enhancing effect on libido.
Turna and colleagues compared levels of various androgenic and non-androgenic hormones in premenopausal (n = 40) and postmenopausal (n = 40) women equally divided between those with and without LLB. Women who reported LLB reported symptoms for at least 6 months, and were in stable relationships were included. Measurements of psychological status (ie, Beck Depression Inventory) and the Female Sexual Function Index (FSFI)were coupled with laboratory analysis including total testosterone (tTST), free testosterone (fTST), estradiol, dehydroepiandrosterone sulfate (DHEA-S), and sex hormone binding globulin (SHBG).
There was a positive correlation between androgens and scores on the FSFI in both premenopausal and postmenopausal women. Similarly, lower androgen levels were associated with lower levels of arousal, lubrication, and orgasm as measured on the FSFI (P < 0.05). Additionally, women with LLB had statistically significantly lower androgen levels than their menopausal-status-matched comparators. These correlations were consistent across tTST, fTST, and DHEA-S.
The role of androgen supplementation in women remains highly controversial. If androgen supplementation is desired, the best method is similarly indeterminate. Nonetheless, such data suggest that attention to the androgen status of women with LLB may merit consideration.
Smoking and ED
Source: Shiri R, et al. Int J Impot Res. 2005;17:164-169.
It is increasingly recognized in the clinical community that erectile dysfunction (ED) most commonly represents endothelial dysfunction associated with any of the risk factors for vasculopathy: eg, diabetes, dyslipidemia, and hypertension. Cigarette smoking (CIG) is also recognized as a potent inducer of vasculopathy, but there are not much data specifically addressing the relationship between CIG and ED. Critical questions for elucidation include the relative risk effects of CIG upon ED, the prognostic effect of CIG upon established ED, and whether ED elicits any modifications in smoking behavior.
This population study included residents from communities around Tampere, Finland aged 50-70 years (n = 2198). Information was obtained at baseline and 5 years later, and included questions on presence, absence, and severity of ED, and smoking status.
There was a trend for increased incidence of ED (OR = 1.4; CI, 0.9-2.3) with smoking; among men who subsequently recovered their erectile function, the rate of recovery was less in those who continued to smoke than those who quit.
Curiously, men who incurred ED more often then began to smoke, so that "smoking causes ED and ED causes smoking." These data support the deleterious relationship of smoking to erectile function. Smokers who continue to smoke are less likely to recover erectile function.
Hip fractures (hip) occur 2-4 times more commonly in persons who have sustained a stroke than an age-matched population.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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