Testosterone substitution with a new transdermal, hydroalcoholic gel applied to scrotal or non-scrotal skin: a multicentre trial

OBJECTIVE

Testosterone-containing gels have improved testosterone substitution therapy, but they are associated with the risk of interpersonal transfer. Therefore, we tested a new hydroalcoholic 2.5% testosterone gel (TGW), which was removed by washing 10 min after administration.

DESIGN

The gel was applied to scrotal or non-scrotal skin in comparison to two 2.5 mg Androderm patches in a randomised, three-arm, parallel-group, controlled multicentre trial over a period of 24 weeks. We included symptomatic hypogonadal men whose morning testosterone levels were <10 nmol/l. Either 1 g TGW was applied to scrotal skin (n = 54) or 5 g to non-scrotal skin (n = 56) once daily; the patch group (n = 52) applied two patches/day. Dose titration was allowed.

RESULTS

Whereas serum testosterone levels and the pre-post changes of the areas under the curve of testosterone and free testosterone between weeks 0 and 24 indicated equivalent treatment success for the patch and scrotal groups, the dermal gel group was significantly superior to the other two groups. Questionnaires on sexual function, mood and quality of life did not differ significantly between study groups, nor were prostate volume, prostate-specific antigen (PSA) levels and prostate symptoms different. However, tolerability was much better in the gel groups than the patch group.

CONCLUSION

Efficacy, safety and tolerability suggest TGW as a favourable treatment for hypogonadal patients.

A comparative study on attitudes, mental health and job stress amongst GPs participating, or not, in a rural out-of-hours co-operative

OBJECTIVES

To test the study hypothesis that GPs participating in co-operatives will have more positive attitudes towards co-operatives, better mental health and less stress than GPs using traditional out-of-hours arrangements.

METHODS

A comparative questionnaire study was conducted amongst GPs, participating, or not, in an out-of-hours, largely rural, co-operative ('NoWDOC') which had been established one year previously. The general attitudes of GPs towards out-of-hours work were obtained together with responses to the General Health Questionnaire-12 (mental health) and Stress Arousal Checklist (job stress).

RESULTS

Eighty-nine of 120 eligible practitioners responded (74%). The mean GHQ scores for GPs in NoWDOC was 10.2 [standard deviation (SD) 3.9] compared to a score of 11.3 (SD 4.5) for those not participating (t = -1.18; P = 0.24). The overall mean stress score for members of NoWDOC was 3.8 (SD 2.6) compared to 3.4 (SD 2.7) for non-NoWDOC (t = 0.59; P = 0.55). The overall mean arousal score for NoWDOC GPs was 5.2 (SD 2.0) compared to 5.5 (SD 2.9) for non-NoWDOC GPs (t = -0.68; P = 0.50). Multiple regression analyses suggested that the independent variables (partnership arrangements, age, working hours and membership of NoWDOC) did not account for any of the variability in the GHQ score but a significant amount of variability in stress and arousal scores.

CONCLUSIONS

The anticipated differences in mental health and job stress among participating GPs were not shown. As the new generation of GPs resemble the NoWDOC participants in their preferences for multi-partner practices with limited out-of-hours care provision, clarification of these findings is important.

The effect of health status on patients' satisfaction with out-of-hours care provided by a family doctor co-operative

BACKGROUND

Systems for providing primary care outside normal hours have changed significantly in Europe over the last 20 years. The impetus for this change has come almost entirely from the medical profession, and it is important to consider the patients' perspective. Although patient's satisfaction with out-of-hours care has been studied extensively, the effect of patient's health status on satisfaction level has not been examined previously.

OBJECTIVES

The primary objective of this study was to investigate whether health status has an influence on patient satisfaction with out-of-hours care provided by a family doctor co-operative. The secondary objective of this study was to investigate the impact of age, gender, socio-economic status and call outcome on patients' satisfaction with out-of-hours care.

METHODS

All patients contacting the service over a designated 24 day period were forwarded a postal questionnaire. Health status was recorded using the Short Form-12 (SF-12) health survey. Patients' satisfaction was measured by using a version of the McKinley questionnaire.

RESULTS

The response rate was 55% (531 out of 966). Overall satisfaction levels were high, with 88% of patients rating the service as either excellent or good. Logistic regression, modelling for the simultaneous effects of age, gender, socio-economic status, call outcome and health status on overall satisfaction, found that patients with lower physical and mental health status scores were significantly less likely to be satisfied with their out-of-hours care [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07, P = 0.017; and 1.03, 95% CI 1.00-1.06, P = 0.046, respectively]. Patients with higher socio-economic status were also significantly less likely to be satisfied (OR 0.25, 95% CI 0.11-0.55, P = 0.001). Patient's age and gender, and call outcome did not significantly affect overall satisfaction levels.

CONCLUSION

Family doctor co-operatives have significantly altered the way out-of-hours care is delivered. Patients with lower health status are significantly less likely to be satisfied with this new form of out-of-hours care. This finding has important implications for the future planning of out-of-hours primary care services.

Effect of rurality on patients' satisfaction with out of hours care provided by a family doctor cooperative

INTRODUCTION

Reacting to demand and supply pressures, European healthcare systems are undergoing significant structural changes to the organisation and delivery of out of hours care. Such pressures are of particular concern to rural practice. Although patient satisfaction with out of hours care has been extensively studied, the effect of rurality on satisfaction levels has not, to our knowledge, been previously examined.

OBJECTIVE

To investigate whether rurality has an influence on patient satisfaction with out of hours care provided by a family doctor co-operative.

METHODS

All patients contacting the service over a designated 24-day period were forwarded a postal questionnaire. Patients' satisfaction was measured using a version of the McKinley questionnaire, and rurality, by subjective patient assessment, distance from treatment centre or previous rota cover.

RESULTS

The response rate was 55% (531/966). Overall satisfaction levels were high with 88% of patients rating the service as either good or excellent. 47.8% of respondents perceived themselves as living in a town, 14.6% as living in a village, and 37.6% as living in the countryside. Perceived rurality, distance from treatment centre or previous rota cover did not significantly affect satisfaction levels.

CONCLUSIONS

Family doctor co-operatives have significantly altered the way out of hours care is delivered. Patients from rural areas are equally satisfied with the provision of out of hours care by co-operatives, as urban patients. Extension of co-operatives to rural areas need not be constrained by concerns regarding decreased patient satisfaction.

Phylogeography and divergence in the chloroplast genome of Western Australian Sandalwood (Santalum spicatum)

Western Australian sandalwood (Santalum spicatum) is widespread throughout Western Australia across the semiarid and arid regions. The diversity and phylogeographic patterns within the chloroplast genome of S. spicatum were investigated using restriction fragment length polymorphism analysis of 23 populations. The chloroplast diversity was structured into two main clades that were geographically separated, one centred in the southern (semiarid region) and the other in the northern (arid) region. Fragmentation due to climatic instability was identified as the most likely influence on the differentiation of the lineages. The lineage in the arid region showed a greater level of differentiation than that in the southern region, suggesting a higher level of gene flow or a more recent range expansion of sandalwood in the southern region. The phylogeographic pattern in the chloroplast genome is congruent with that detected in the nuclear genome, which identified different genetic influences between the regions and also suggested a more recent expansion of sandalwood in the southern region.

Regional genetic differentiation in Western Australian sandalwood (Santalum spicatum) as revealed by nuclear RFLP analysis

Western Australian sandalwood, Santalum spicatum, is widespread in the semi-arid and arid regions of Western Australia, and there is some morphological variation suggestive of two ecotypes. The level and structuring of genetic diversity within the species was investigated using anonymous nuclear RFLP loci. Santalum spicatum showed moderate levels of genetic diversity compared to other Australian tree species. The northern populations in the arid region showed greater levels of diversity and less population differentiation than the southern populations in the semi-arid region due to differences in the distribution of rare alleles. Equilibrium between drift and gene flow in the northern populations indicated that they have been established for a long period of time with stable conditions conducive to gene flow. In contrast, the southern populations showed a relationship between drift and gene flow indicative of a pattern of fragmentation and isolation where drift has greater effect than gene flow. The different patterns of diversity suggest that the ecotypes in the two regions have been subject to differences in the relative influences of drift and gene flow during their evolutionary history.

Collagenase cleavage of type I collagen is essential for both basal and parathyroid hormone (PTH)/PTH-related peptide receptor-induced osteoclast activation and has differential effects on discrete bone compartments

Expression of a constitutively active PTH/PTHrP receptor in cells of osteoblast lineage in vivo (CL2+) causes increases in trabecular bone volume and trabecular bone formation and, conversely, a decrease in the periosteal mineral apposition rate. Collagenase-3 (matrix metalloprotease-13) is a downstream target of PTH action. To investigate the relevance of collagenase cleavage of type I collagen for the CL2+ bone phenotype, we bred CL2+ animals with mice carrying a mutated col1 alpha 1 gene that encodes a protein resistant to digestion by collagenase-3 and other collagenases (rr). Adult tibias and parietal bones from 4-wk-old double-mutant animals (CL2+/rr) and from control littermates were analyzed. Trabecular bone volume was higher in CL2+/rr than in CL2+ mice. This increase occurred despite a modest reduction in bone formation rate, which was, however, still significantly higher that in wild-type littermates, and therefore must reflect decreased bone resorption in rr mice. Osteoclast number was increased in CL2+/rr animals compared with either wild-type or CL2+ mice, suggesting that collagenase-dependent collagen cleavage affected osteoclast function rather than osteoclast number and/or differentiation. Interestingly, the periosteal mineral apposition rate was similar in CL2+/rr and CL2+ animals and was significantly lower than that in wild-type animals. Our study provides evidence that collagenase activity is important for both basal and PTH/PTHrP receptor-dependent osteoclast activation. Furthermore, it indicates that a mild impairment of osteoclast activity is still compatible with increased osteoblast function. Lastly, it supports the hypothesis that collagenases can be a downstream effector of PTH/PTHrP receptor action in trabecular bone, but not in periosteum.

Testosterone replacement therapy in male hypogonadism

In human males 6-7 mg of testosterone are secreted by the testes in a circadian rhythm with a nocturnal rise in testosterone followed by a decline during the day. Testosterone is necessary to induce and maintain secondary sexual characteristics, lean muscle mass, bone density and for normal sexual behaviour and cognitive function in men. Replacement therapy has been shown to be beneficial in men with overt hypogonadism. Natural testosterone should be used and not modified molecules. Testosterone is currently available in oral, intramuscular, subcutaneous and transdermal preparations. Recent advances in testosterone replacement therapy include testosterone gels which provide flexibility in dosing and minimal skin irritation resulting in good compliance, and the development of longer acting intramuscular preparations which result in more stable testosterone levels with longer injection intervals. All patients receiving testosterone should be carefully monitored for changes in hematocrit, liver function, lipid parameters and prostate specific antigen (PSA).This article reviews the current experience with the use of various forms of testosterone for the treatment of male hypogonadism.

Efficacy and tolerability of fixed-dose combinations of telmisartan plus HCTZ compared with losartan plus HCTZ in patients with essential hypertension

Telmisartan, an angiotensin II receptor blocker, is an effective once-daily antihypertensive agent available either alone or in fixed-dose combination with hydrochlorothiazide (HCTZ). This multicentre, prospective, randomised, open-label, blinded-endpoint (PROBE) study assessed the efficacy and safety of six weeks' treatment with telmisartan 40 mg/HCTZ 12.5 mg (n = 199) and telmisartan 80 mg/HCTZ 12.5 mg (n = 200) versus losartan 50 mg/HCTZ 12.5 mg (n = 198) in patients with mild to moderate essential hypertension. During the last six hours of the dosing interval, telmisartan 40 mg/HCTZ 12.5 mg and telmisartan 80 mg/HCTZ 12.5 mg reduced mean ambulatory diastolic blood pressure (DBP) to a greater extent than losartan 50 mg/HCTZ 12.5 mg (treatment differences 1.8 mmHg [p < 0.05] and 2.5 mmHg [p < 0.001], respectively). Telmisartan 80 mg/HCTZ 12.5 mg also lowered mean 24-hour DBP by 2.3 mmHg more than losartan 50 mg/HCTZ 12.5 mg (p < 0.001). Telmisartan 40 mg/HCTZ 12.5 mg and telmisartan 80 mg/HCTZ 12.5 mg produced greater reductions in ambulatory systolic blood pressure versus losartan 50 mg/HCTZ 12.5 mg of 2.5 mmHg and 3.4 mmHg, respectively, during the last six hours of the dosing interval (p < 0.05), and of 2.1 mmHg and 3.4 mmHg, respectively, over the entire 24-hour dosing interval (p < 0.05). All treatments were well tolerated.

Self-rated schizotypal cognitions, psychotic symptoms and the onset of schizophrenia in young people at high risk of schizophrenia

OBJECTIVE

To examine the associations between the Rust Inventory of Schizotypal Cognitions (RISC) and psychotic symptoms measured by the Present State Examination (PSE) and to assess the predictive validity of the RISC for later onset of schizophrenia.

METHOD

A total of 154 subjects at high risk for schizophrenia but who were currently well, 35 well controls and 28 first episode schizophrenic patients were assessed on specified PSE symptoms and completed the RISC. A subsample of the high risk group was subsequently monitored for onset of schizophrenia over 39 months.

RESULTS

RISC scores at entry were significantly higher in subjects with psychotic symptoms on PSE. There were indications that high scorers on the RISC were likely to develop schizophrenia. However, less than half of those falling ill exhibited high RISC scores on entry.

CONCLUSION

The RISC scale is highly associated with presence of psychotic symptoms on PSE and high scorers may be at increased risk of schizophrenia onset.

Recent advances in the design and performance of research assistants

Every laboratory needs personnel who work 24 hours a day 7 days a week, are efficient, obedient, capable of showing initiative, insightful and affable. Our experience of laboratory workers tells us that there is an immense way to go to achieve these goals. Having tired of the normal, Darwinian approach, a project has been initiated to achieve these ends through genetic technologies.

Massive pseudotumour resection with recombinant factor VIIa (NovoSeven) cover

Surgical resection is the only definitive treatment for haemophilic pseudotumour. For patients with high- responding factor (F)VIII inhibitors, the lack of reliable by-passing agents in the past has meant that surgery has been avoided in favour of conservative measures. The development of recombinant factor VIIa (rFVIIa) has revolutionized the management of surgery in these patients. We document the first successful report of the surgical resection of a massive pseudotumour in a patient with high responding FVIII inhibitors using rFVIIa to achieve haemostasis. Serial post-operative measurements indicated that FVII coagulation activity (FVII:C) levels were more sensitive to rFVIIa dose changes than the prothrombin time.

von Willebrand's disease: an important cause of dysfunctional uterine bleeding

We assessed the prevalence of von Willebrand's disease (VWD) in patients with objectively confirmed dysfunctional uterine bleeding. A case-control study was designed to include 38 patients with objectively confirmed dysfunctional uterine bleeding and 38 age-matched controls with normal menstrual blood loss (MBL). Menorrhagia was defined as a mean MBL of greater than 80 ml on three consecutive menses as measured by the alkali haematin method. von Willebrand factor antigen, von Willebrand factor activity (VWF:Ac) and factor VIII:C were measured on three serial venous blood samples 1 week apart. VWD was diagnosed in five of 38 (13%) patients with menorrhagia and one of 38 (2.6%) patients with normal menstrual blood loss. The mean VWF:Ac value was significantly reduced in patients with menorrhagia (mean +/- standard deviation, 84.5 +/- 26.7 IU/dl versus 103.9 +/- 34.5 IU/dl; P < 0.01) and this effect persisted after exclusion of patients diagnosed with VWD. Failure to investigate patients for VWD will limit the potential benefits of medical therapies such as tranexamic acid or nasal desmopressin [1-desamino-8-D-arginine vasopressin, (DDAVP)] and, in addition, will lead to an increased risk associated with surgical intervention in patients with undiagnosed VWD.

Tuberculosis of the cervix: case presentation and a review of the literature

Cervical tuberculosis is uncommon in the developed world. We describe a patient who attended a genitourinary medicine clinic, and who was found to have cervical tuberculosis, in association with HIV infection.