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By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for Abbott, AstraZeneca, Boehringer Ingelheim, Daiichi, Sankyo, Forest Pharmaceuticals, Lilly, Novo Nordisk, Takeda.
Safety of testosterone replacement
Source: Basaria S, et al. Adverse events associated with testosterone administration. N Engl J Med 2010;363:109-122.
Of late, there has been a renaissance of interest in identification and management of hypogonadism in older men. This new enthusiasm is based upon a recognition that subnormal testosterone is both common and consequential. For instance, prevalence studies suggest that as many as 40% of healthy men older than age 50 have a subnormal morning total testosterone level. Subnormal testosterone is associated with changes in sexual function, mood, muscle mass, and central obesity. Observational data indicate that low testosterone is also associated with increased mortality. The advent of better-tolerated, easy-to-use testosterone replacement modalities (e.g., patches, gels, buccal tablets), has simplified the treatment approach, but the question about long-term testosterone safety is unanswered.
In the Testosterone in Older Men with Mobility Limitations study of senior men (n = 209; mean age, 74 years), subjects were treated with testosterone 1% gel to achieve mid-normal testosterone levels. The trial was discontinued early upon the recommendation by the Data and Safety Monitoring Board because of an increase in adverse events in the treatment group, including some serious events. For instance, there were 23 CV adverse events in the treatment group, compared with 5 in the placebo group.
The small size of the trial and the highly selected group (men with physical limitations) makes it difficult to generalize about the results. Nonetheless, clinicians should recognize that testosterone replacement may be associated with important adverse events. Larger, long-term studies will be necessary to establish the safety profile of testosterone replacement.
Is obesity a factor in asthma?
Source: Pakhale SM, et al. A comparison of obese and nonobese people with asthma: Exploring an asthma-obesity interaction. Chest 2010;137:1316-1323.
Population studies have shown that obesity is related to the incidence of asthma. Compared to non-obese subjects, the odds ratio per year for developing asthma among obese individuals is approximately 1.5, and increases as the degree of obesity increases. Although mechanisms through which obesity might contribute to incident asthma are poorly understood, several prospective studies have demonstrated the same relationship.
Of course, some persons who carry a diagnosis of asthma have been misdiagnosed. In this study by Pakhale et al, subjects diagnosed as asthmatic underwent formal pulmonary function testing to confirm their diagnosis. Overall, of 496 subjects, asthma was ultimately ruled out in 150 of them. Likelihood of misdiagnosis was increased especially in older males.
There was one subgroup of obese individuals among whom the likelihood of asthma misdiagnosis stood out: If an obese individual had had an urgent visit for respiratory symptoms in the past 12 months, the misdiagnosis of asthma was more than 4-fold greater than in non-obese persons.
Based upon this information, it is suggested that clinicians should consider performing objective confirmation of the diagnosis of asthma (as with pre- and post-bronchodilator spirometry), particularly among obese older males.
A new tool for treatment of plantar warts
Source: Gamil H, et al. Intralesional immunotherapy of plantar warts: Report of a new antigen combination. J Am Acad Dermatol 2010;63:40-43.
Plantar warts, most commonly found on the plantar surface of the feet but also seen on the hands and other sites, are often challenging to treat. Although available tools include destructive therapies (e.g., cryotherapy, bichloroacetic acid), topical immune modulators (e.g., imiquimod), oral agents (e.g., cimetidine, levamisole), and simple surgical excision, each of these modalities has limitations. Hence, new methods of intervention are sought.
Gamil et al investigated the use of intralesional measles/mumps/rubella vaccine (MMR, as used in standard childhood immunizations) in a pilot trial. Vaccine was injected once every 3 weeks for a maximum of three injections, in 23 subjects.
Although the duration of treatment was only 6 weeks (injections at time 0, 3 weeks, and 6 weeks), patients were followed for 9 months to evaluate for recurrence.
Complete clearance of warts occurred in 20 of 23 patients, 1 patient had partial clearance, and 2 had no response. Only 1 patient experienced recurrence over 9 months. Other than local pain during the actual process of injection, the only other reported adverse effect was a transient flu-like syndrome in 1 patient.