Clinical Briefs By Louis Kuritzky, MD
Clinical Briefs
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.
The Emperor's new vertebroplasty?
Source: Buchbinder R, et al. N Engl J Med 2009;361:557-568.
Vertebroplasty (VERT) has recently enjoyed increased popularity as treatment for painful osteoporotic vertebral fractures. Observational or open-label studies have provided most of the supportive information. Enthusiasm for other previously popular surgical procedures has been dampened when double-blind randomized trials have failed to confirm positive outcomes: Two randomized trials in the last 7 years comparing arthroscopy for knee osteoarthritis found no outcomes difference when compared to placebo.
Buchbinder et al performed a randomized, double-blind, sham procedure-controlled trial of VERT for painful osteoporotic fracture in 78 participants. The primary outcome measurement was pain reduction, which did not differ at weeks 1, 3, or 24 after treatment between intervention and sham intervention.
The Buchbinder study was published together with another VERT trial in the New England Journal of Medicine examining pain and disability at 1 month post intervention, which similarly did not find positive outcomes. These trials call for closer evaluation of the (potential) value of VERT.
Parsing the death toll of COPD
Source: Zvezdin B, et al. Chest 2009; 136:376-380.
Worldwide, COPD is the fourth leading cause of death; unless current trends reverse, the toll will rise. Mortality rates associated with hospitalized acute exacerbations of COPD have been as high as 30%; the mortality in the 1 year after hospitalization is as high as 43%. Some of this mortality is directly attributable to COPD; however, other prominent comorbidities (e.g., CVD, pulmonary embolism) are also responsible. Often, because post-mortem examination is limited, the cause of death can only be opined. To provide greater clarity, Zvezdin et al report on autopsies of 43 patients who died within 24 hours of COPD hospital admission.
The mean age of the study subjects was 70. According to autopsy results, more than half of the deaths were attributed to diagnoses other than COPD: heart failure (in 37%) and pulmonary embolism (in 21%). The authors also separate pneumonia as a "non-COPD" cause of death (occurring in 28%), defining COPD death as those individuals who die of respiratory failure due to COPD progression (14%).
If these results (from a Serbian tertiary care university hospital specializing in pulmonary diseases) are generalizable to U.S. populations, clinicians will need to exercise greater vigilance, enhanced preventive techniques, and intensified intervention for potentially fatal comorbidities when patients are admitted for acute COPD exacerbation.
Vardenafil and premature ejaculation
Source: Aversa A, et al. Int J Impot Res 2009;21:221-227.
Although clinicians are much more familiar with erectile dysfunction, over the lifespan premature ejaculation (PEJ) is more common. A much smaller percentage of men with PEJ seek help, attributable to factors such as embarrassment, absence of available FDA-approved medications, and lack of public awareness of PEJ as an important sexual health dysfunction.
The technical definition of PEJ is a matter of controversy, although most experts agree that consistent unintended/unwanted ejaculation within 1 min that causes distress is satisfactory for the diagnosis.
The most commonly used metric for measuring PEJ is intravaginal ejaculatory latency time (IELT), or the time after vaginal intromission at which ejaculation occurs. Population studies have suggested that in established heterosexual couples, typical IELT is 6-10 min. Subjects enrolling in PEJ trials typically have an IELT of 30-90 sec, or even ejaculation ante portis (prior to intromission). The above definition would, by construction, seem to exclude gay men or ejaculation involving other orifices/body parts, but the similarities of diagnosis and management of PEJ in gay couples suggest that IELT, while at times anatomically inconsistent, incorporates the broader concepts of early ejaculation in a variety of sexual settings.
SSRIs have an established role in the management of PEJ. Success with SSRIs is greatest when taken on a maintenance schedule; however, patients would generally prefer as-needed administration, all things being equal.
Aversa et al studied men with PEJ (n = 42), all of whom consistently experienced IELT < 1 min. Patients were randomized (double-blind) to placebo or vardenafil 10 mg administered 15-30 min before sexual activity. The primary outcome was change in IELT.
Use of vardenafil provided a significant improvement in IELT (from 36 sec to 4.5 min) compared with placebo (IELT went from 42 sec to 54 sec). The tolerability of vardenafil is well established. Vardenafil appears to be a viable option for PRN treatment of PEJ.
Vertebroplasty (VERT) has recently enjoyed increased popularity as treatment for painful osteoporotic vertebral fractures.Subscribe Now for Access
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