Title: MEETINGS , Modern Medicine, 00268070, Sep99, Vol. 67, Issue 9
Sildenafil effectively treats erectile dysfunction in diabetic men
Sildenafil citrate is an effective and well-tolerated treatment for erectile dysfunction (ED) in diabetic men, report the authors of this randomized, double-blind trial carried out in Seattle.
STUDY DESIGN. The study included 252 men (age >/= 18) with a documented history of ED for at least 6 months, and either type 1 diabetes for at least 5 years or type 2 diabetes for at least 2 years; the medical management of their diabetes was stable for at least 12 weeks. After a 4-week run-in phase, participants were started on either Sildenafil 50 mg daily or placebo. The initial dose of Sildenafil could be adjusted to 25 mg or 100 ms, depending on efficacy and tolerability. Treatment efficacy was assessed after 12 weeks by patient interview.
RESULTS. The ability to achieve and maintain erections was significantly improved in diabetic patients who received Sildenafil compared with placebo. Fifty-one percent of diabetic men treated with Sildenafil reported improvements in erections, and 49% cited improvements in the ability to have sexual intercourse. Only 12% of diabetic men assigned to placebo said they had improvements in their erections, and only 12% said their ability to have sexual intercourse was improved. Patients who responded best to Sildenafil treatment were those with fewer diabetes-associated complications, such as retinopathy, nephropathy, neuropathy, and cardiovascular disease.
Treatment with Sildenafil was well tolerated. While serious adverse events did occur in the placebo group (n=4) and the Sildenafil group (n=3), none resulted from treatment, according to the investigators.
Irl B. Hirsch, MD
Dr. Hirsch is an Associate Professor of Medicine at the University of Washington in Seattle, and Medical Director of the University’s Diabetes Care Center.
“Our results clearly show that Sildenafil works well in diabetic men with ED. This is good news, since approximately half of diabetic men suffer from ED. On the other hand, men without diabetes have been found to have a higher response rate to Sildenafil , ranging from 70% to 75%.”
American Diabetes Association 59th Scientific Session
June 19-22, 1999. San Diego, Calif.
Irl B. Hirsch, MD
Based on various trials, the American Diabetes Association earlier this year recommended daily aspirin therapy (81-325mg/day) for the secondary prevention of cardiovascular disease in men and women with evidence of large-vessel disease, and for primary prevention of cardiovascular disease in high-risk individuals. However, according to researchers in Atlanta, diabetic patients who are candidates for aspirin therapy are not taking their aspirin as recommended.
STUDY DESIGN. The frequency and determinants of aspirin use were evaluated in 1503 adult diabetics who had participated in the Third National Health and Nutrition Examination Survey (NHANES) between 1988 and 1994. Survey respondents underwent detailed interviews, and physical and laboratory examinations. In the present investigation, persons who said they took aspirin at least 15 times in the preceding month were considered to be regular users.
RESULTS. Ninety-eight percent of adult diabetics were candidates for aspirin therapy. However, only 20% of eligible individuals took aspirin regularly during the study period. Even among those with cardiovascular disease (a history of myocardial infarction, stroke, claudication, or angina), only 37% used aspirin. Individuals most likely to use aspirin regularly were those with established cardiovascular disease, those at least 40 years of age, and non-Hispanic whites.
American Diabetes Association 59th Scientific Session
June 19-22, 1999. San Diego, Calif.
Deborah B. Rolka, MS
Reducing iron stores before and during treatment of hepatitis C virus (HCV) infection may enhance the efficacy of interferon, according to Robert Fontana, MD.
STUDY DESIGN. In a multicenter study, 82 noncirrhotic, treatment-naive HCV-positive patients were randomized to either interferon for 24 weeks or iron reduction, followed by iron reduction plus interferon for 24 weeks. Those in the iron-reduction group had weekly whole-blood phlebotomy to achieve mild iron deficiency. A mild iron-deficient state was maintained with phlebotomy during interferon treatment.
OUTCOMES. Serum ferritin levels decreased in the iron-reduction group by week 4. Serum alanine aminotransferase (ALT) levels were lower during treatment and at the end of treatment in the iron-reduction group, compared with the interferon-only group. Hepatitis viral RNA levels were also lower during treatment, at the end of treatment, and at 6-months’ follow-up in the patients who underwent phlebotomy. The virologic response at the end of treatment was significantly greater in the iron-reduction/interferon group versus the interferon-only group.
Six months following the end of treatment, there were about twice as many virologic and biologic responders among the patients randomized to iron reduction compared with those randomized to interferon alone, although the difference was not statistically significant. There was also a trend toward greater improvement in liver histology in the iron-reduction group.
Robert Fontana, MD
Dr. Fontana is an Assistant Professor of Medicine with the Division of Gastroenterology, University of Michigan, Ann Arbor.
“Iron reduction has not yet been established in my opinion” Dr. Fontana told MODERN MEDICINE. “Larger groups of patients and perhaps studies of longer duration are needed to determine if iron reduction combined with interferon is going to be a potentially new and effective means of managing hepatitis C.”
Iron is a comorbid factor in HCV infection, he said. “increased hepatic iron stores have been documented in some patients with HCV infection. About 40% to 50% of NCr-positive patients have elevated serum levels of iron” he said. Some patients with lower circulating levels of iron may have improved responsiveness to interferon. An improvement or normalization of ALT levels has also occurred with reduction of iron stores via phlebotomy in HCV-infected patients.
Digestive Disease Week
May 16-19, 1999. Orlando, Fla.
Robert Fontana, MD
Full colonoscopy appears to be an effective screening test for detecting early advanced colon neoplasia in middle-aged and older asymptomatic men, according to David Lieberman, MD.
METHODS. The Veterans Affairs (VA) Cooperative Colonoscopy Screening Study reported on the prevalence of colorectal polyps in an asymptomatic cohort of 3119 subjects aged 50 to 75 years. Almost all (97%) of the participants were men. A family history of colorectal cancer was present in 14%. The authors also sought to determine whether a limited examination of the left colon up to the splenic flexure would be able to detect most patients with serious colorectal pathology.
A complete screening colonoscopy was performed in all of the study enrollees. The participants were recruited from the general medical clinics of 13 VA centers. None of them had undergone colorectal screening within the past 10 years. All polyps found on colonoscopy were photographed, measured, and removed.
RESULTS. Overall, 5171 polyps were found. More than one third (36%) of them had adenomas of any size, 8.5% had adenomas measuring 1 cm or greater, and 1.6% had adenomas with high-grade dysplasia. Adenomas with high-grade dysplasia are at risk for progression to invasive cancer. Invasive cancer was found in 1.0% of the cohort. Most of the cancers found were at an early and curable stage–22 of the 30 had neither nodal involvement nor metastases.
Patients who had adenomas of any size had a 2.8-fold increased risk for serious pathology in the proximal colon, compared with patients that had no polyps. Most of the serious neoplasms were found in the left side of the colon, but 36% of patients with advanced polyps had lesions in the right colon. Fewer than half of the patients with polyps in the proximal colon had an index or marker lesion that would have been found on flexible sigmoidoscopy.
David Lieberman, MD
Dr. Lieberman is a Professor of Medicine and Chief of the Division of Gastroenterology, Oregon Health Sciences University, Portland.
“Our study shows that although most patients with advanced neoplasia could be detected with a flexible sigmoidoscopy up to the splenic flexure, many patients with significant lesions in the proximal colon would not be detected,’ said Dr. Lieberman in an interview with MODERN MEDICINE.
“There is a lot of controversy over whether patients who have small adenomas in the left side of the colon on sigmoidoscopy should go ahead and have a full colon examination. The patients with distal adenomas did have an increased risk of having serious lesions in the other portion of the colon that would not be examined. These data therefore support performing full colonoscopy if any adenoma is discovered in the distal colon”
The results of the study apply only to men, Dr. Lieberman emphasized. Women 50 to 75 years old tend to have fewer polyps than men of the same age.
Digestive Disease Week
May 16-19, 1999. Orlando, Fla.
David Lieberman, MD
The misdiagnosis of breast cancer and the nonuse of preventive strategies in its treatment generate more malpractice suits than any other claim of misdiagnosis, said Kenneth Kern, MD.
Suits that claim a diagnostic delay usually involve patients who are under the age of 45 with a false-negative mammogram and a self-discovered breast mass. Physicians frequently lose these often-costly suits because they employ no other diagnostic method beyond mammography after the patient’s discovery of the breast mass. Dr. Kern drew his data from several sources, including the Physician Insurers Association of America and the National Cancer Institute’s Surveillance, Epidemiology and End-Results Reporting Program (SEER).
In claims of misdiagnosis, physicians found a palpable mass on initial presentation in almost 75% of cases. But in more than 50% of such cases, there was a negative mammogram. “It’s almost random whether you will see something definitive or not in a mammogram for a woman under 50,” Dr. Kern said. To avoid lawsuits and diagnostic delays, Dr. Kern advised liberal use of fine-needle aspiration, and core and open-surgical biopsy when a palpable mass exists.
Kenneth Kern, MD
Dr. Kern is an Associate Clinical Professor of Surgery at the University of Connecticut School of Medicine and Dartmouth Medical School.
“Physicians are lulled into the misdiagnosis of breast cancer by the young age of patients and false-negative readings of mammography, not by vague findings or difficult diagnostic situations.”
American College of Obstetricians and Gynecologists 47th Annual Clinical Meeting
May 15-19, 1999. Philadelphia, Pa.
Kenneth Kern, MD
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