What is the Best Way to 'Predict' Diabetes: IFG, IGT, or A1c?

Source: Droumaguet C, et al. Diabetes Care. 2006;29:1619-1625.

The American Diabetes Association (ADA) does not advocate use of the A1c for diagnosing diabetes. Rather, they suggest use of fasting or random glucose, or oral glucose tolerance testing (GTT). Most commonly, the diagnosis is made by means of the fasting or random measurement, since GTT is more cumbersome, expensive, and less convenient. Other authors have suggested that A1c might be a reasonable way to diagnose diabetes, since we only intervene with treatment when the A1c is above a particular threshold (> 7.0, according to the ADA). The ADA points out that although there is a national standard test for A1c, laboratories are not required to use it; we are in a similar state with A1c to where we used to be with the Pro-time for Coumadin monitoring: it varied from hospital to hospital. Then came the INR, so that now the results are standardized across all hospitals. We do not yet enjoy a similar universal standardization of A1c. Additionally, the A1c appears to be less sensitive to very early abnormalities of glucose as detected by IFG or IGT.

The DESIR study provided data on 2,720 men and women who were defined as being 'at-risk' on the basis of an elevated fasting glucose. These individuals also had A1c measured and were followed for 6 years.

A1c was less sensitive and less specific than fasting glucose for predicting diabetes. If some circumstance prevents patients from obtaining a fasting glucose measurement, A1c provides a second-best predictive value.

Hair Growth With Finasteride: Not Just More, but More Better!

Source: Price VH, et al. J Am Acad Derm. 2006;55:71-74.

Male pattern baldness is a result of the impact of dihydrotestosterone (DHT) upon scalp hair follicles which results in a progressive miniaturization of follicles leading to thinner, shorter hairs in genetically susceptible men. Scalp biopsy has shown that susceptible men have higher levels of cutaneous DHT, more cutaneous 5-alpha-reductase (the hormone responsible for converting testosterone to DHT), and more androgen receptors than comparator groups.

Finasteride is a 5-alpha-reductase inhibitor (5ARI), which prevents production of DHT from testosterone. In this trial, subjects were given standard oral doses of finasteride (1 mg/d) or placebo for 4 years.

Active treatment produced a significant effect upon hair weight and hair count. For instance, by week #192, hair weight had increased by 21.6% in the treatment group, but had decreased by 24.5% in the placebo group, for a net increase of 46% compared to placebo. Finasteride has a favorable impact both upon the number of scalp hairs and their size.

Prevalence of Diabetic Neuropathy

Source: Davies M, et al. Diabetes Care. 2006;29:1518-1522.

The relevance of diabetic peripheral neuropathy (DPN), and its commonplace sequela of diabetic peripheral neuropathic pain (DPNP) has recently been highlighted by an American Diabetes Association survey that indicates a distressingly low level of patient awareness of this disorder or its importance. Since diabetes remains the number 1 cause of non-traumatic limb loss in the United States, and DPN is the most common antecedent, it is critical to heighten clinician attention to identification and management of persons with DPN or DPNP. Epidemiologic prevalence data may help to drive clinician awareness.

This cross-sectional survey of a population in South Wales, United Kingdom incorporated both a postal survey and neurologic examination to define the presence of DPN and DPNP. Of 326 diabetic persons who responded to the postal survey that they had "burning, aching, or tenderness in your legs or feet," evaluation by a neurologist indicated that DPNP was the etiology in 19% of the cases. In persons with DPNP, the vast majority (80%) reported the degree of pain as moderate to severe. Persons with DPNP demonstrated a poorer quality of life than persons with non-neuropathic pain.

The authors comment that extrapolating these data to the diabetic population of the United Kingdom, as many as a half million persons suffer DPNP, most of whom endure pain of moderate or greater intensity. To date, in this population only approximately half of DPNP sufferers have sought treatment.

Hypogonadism is Surprisingly Common in Middle-Aged Men

Source: Mulligan T, et al. Int J Clin Pract. 2006;60:762-769.

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 prior 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.

Carpal Tunnel Syndrome: Capturing the Benefits of MultiModal Treatment

Source: Baysal O, et al. Int J Clin Pract. 2006;60:820-828.

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.

Diastolic Dysfunction: Not So Benign

Source: Bhatia RS, et al. N Engl J Med. 2006;355:260-269.

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 the time of diagnosis of 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.