Clinical Briefs by Louis Kuritzky, MD
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for Sucampo Pharmaceuticals, Takeda, Boehringer Ingelheim; and is a consultant and on the speaker's bureau for Novo Nordisk, Lilly, Daiichi Sankyo, Forest Pharmaceuticals, Cephalon, Novartis, and Sanofi Aventis.
Surgery vs Medical Treatment for CTS
Source: Jarvik JG, et al. Lancet 2009; 374:1074-1081.
Several trials comparing surgical with medical therapy for carpal tunnel syndrome (CTS) have been insufficient to clarify the optimum approach. Similarly, it is largely unknown which CTS characteristics predict a favorable response to either type of treatment. Jarvik et al conducted a controlled trial of CTS patients (n = 116) randomized to medical or surgical treatment. Additionally, wrist MRI and nerve conduction studies were performed to identify the predictive capacity of these metrics.
Surgical intervention consisted of either open or endoscopic carpal tunnel decompression (per surgeon preference). Medical treatment included ibuprofen 200 mg tid, physical therapy provided by a hand therapist, other analgesics, corticosteroid injections, and ultrasound (all as per clinician preference). The primary outcome was function as measured by the Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ) at 12 months.
There were no serious adverse events in either treatment group. At 12 months, although both groups showed substantial improvement, the CTSAQ score was significantly better in the surgical group. Study subjects with baseline nerve conduction deficits responded less well to surgical intervention. On MRI, patients with signs of nerve edema (indicative of more advanced disease severity) had successful outcomes (30% improvement on the CTSAQ) only half as often as those without edema. In patients with more severe baseline disease, difference in outcome between surgery and medical management diminished. Overall, surgical intervention provides outcomes that are superior to medical therapy. MRI and nerve conduction data may assist patient selection.
Does Metformin Affect Thyroid Function?
Source: Cappelli C, et al. Diabetes Care 2009;32:1589-1590.
Diabetes commonly is comorbid with other endocrinopathies, including hypothyroidism and hypogonadism. The most common first-line pharmacotherapy for diabetes is metformin, which has been heretofore considered an essentially benign drug, when proscriptions for its use (e.g., renal insufficiency, heart failure) are observed. Recent reports have suggested that metformin might have an effect on TSH even when levothyroxine replacement doses are kept constant; since many hypothyroid patients are diabetic, such effects may be worthy of note.
Capelli et al evaluated in a pilot study 11 diabetic patients with hypothyroidism who initiated therapy with metformin. All had been on stable doses of levothyroxine. Thyroid studies (TSH, free T4 and T3, and total T4 and T3) were performed at baseline, 6 hours, 24 hours, 72 hours, and 3 and 6 months after initiation of metformin. They included in their analysis additional data from another study population comprised of diabetics receiving thyroid for various indications, diabetics with subclinical hypothyroidism not receiving levothyroxine replacement, and diabetics with normal thyroid function.
During the pilot study, despite continued stable levels of levothyroxine replacement and other thyroid parameters, the mean TSH dropped from 2.11 to 1.5 mIU/L. Omission of metforminin one patient who had experienced amore dramatic TSH decline resulted in a return of TSH to baseline. Particularly in the diabetic group with subclinical(non-replaced) hypothyroidism, the decline in TSH was apparent: from a mean of 4.5 to 2.93 mIU/L at 1 year. The mechanism by which metformin lowers TSH is not known.
Beleaguered Primary Care Clinicians
Source: Krasner MS, et al. JAMA 2009;302:1284-1293.
If data obtained within the last 5 years are correct, the majority of primary care physicians (PCPs) reportemotional exhaustion, depersonalization, and/or low sense of accomplishment collectively called burnout. The favorable results of an intervention to alleviate burnout deserve our focus.
Primary care physicians (n = 70) in Rochester, NY, participated in a year-long intervention: 8 weeks of intensive intervention, followed by once-monthly maintenance for 10 months. Although the complexity of intervention was too great to be captured in this communication, didactic materials (including presentations on dealing with conflict, reflecting on meaningful experiences, etc.), meditation (including yoga-type exercises), and narrative exercises (for instance, writing and sharing brief stories about challenging experiences in practice) were included. Sessions occupied 2.5 hours/week for 8 weeks, followed by monthly maintenance 2.5-hour sessions for 10 months. A single all-day session of mindfulness meditation was included during week 6-7.
Following the intervention, scores on the Maslach Burnout Inventory showed meaningful improvements. Although this is a time-intensive investment , it is encouraging to see tools through which clinicians might better enjoy, be better fulfilled by, and probably perform more effectively in their practice.A second human papillomavirus (HPV) recombi-nant vaccine has been approved by the FDA.
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