Jennifer J. Miranda, MD, and Marc J. Laufgraben, MD, MBA wHoM sHould a priMary Care pHysiCian evaluate for testosterone defiCienCy? Low testosterone levels in men are not uncommon. There is an age-related decline in testosterone levels, falling by about 1% each year. Approximately 1% of healthy young men have total serum testosterone levels below 250 ng/dl and approximately 20% of healthy men over 60 years old have serum testosterone levels below 250 ng/dl. However, despite the frequency of testosterone deficiency (TD), especially in aging men, significant questions remain over whom to evaluate, what to measure and how to treat. Men with TD commonly experience sexual symptoms such as loss of libido, erectile dysfunction, and decreased volume of ejaculate. More generalized symptoms such as lack of energy, loss of motivation, inability to concentrate, depressed mood, sleep disturbance, and irritability are also frequently seen. Patients may notice loss of muscle strength, muscular aches, hot flushes, and slow beard growth. Sexual symptoms (low libido and erectile dysfunction) correlate best with low testosterone levels, with generalized symptoms being substantially less specific. Unfortunately, even sexual symptoms have reduced specificity for TD due to the common occurrence of neurovascular causes of erectile dysfunction in aging men, as well as the many physical illnesses and psychosocial stresses that can result in low libido. Physicians may also suspect TD if they note loss of body hair, very small or “shrinking” testes, height loss, or reduced muscle bulk. TD should also be considered in men with certain clinical disorders where the prevalence of TD is high or for whom therapy may be recommended. Such disorders include sellar mass or radiation to the sellar region; HIV-associated weight loss; end-stage renal disease and maintenance hemodialysis; osteoporosis or low-trauma fracture; moderate to severe COPD; infertility; and treatment with medications that affect testosterone production such as glucocorticoids or opioids. TD is also very common in patients with type 2 diabetes. It is important to note that selfreport case-detection instruments such as the Androgen Deficiency in Aging Males ( ADAM) questionnaire have poor specificity and are not recommended. Population-based screening in older men is also not recommended. In summary, primary care physicians should pursue evaluation for TD in men with sexual symptoms or with disorders commonly associated with TD. Evaluation for TD can also be considered in men with more generalized symptoms.
Abstract We describe the creation and quality assurance of a dataset containing nearly all available precinct-level election results from the 2016, 2018, and 2020 American elections. Precincts are the smallest level of election administration, and election results at this granularity are needed to address many important questions. However, election results are individually reported by each state with little standardization or data quality assurance. We have collected, cleaned, and standardized precinct-level election results from every available race above the very local level in almost every state across the last three national election years. Our data include nearly every candidate for president, US Congress, governor, or state legislator, and hundreds of thousands of precinct-level results for judicial races, other statewide races, and even local races and ballot initiatives. In this article we describe the process of finding this information and standardizing it. Then we aggregate the precinct-level results up to geographies that have official totals, and show that our totals never differ from the official nationwide data by more than 0.457%.
We created a concise nurse-driven delirium reduction workflow with the aim of reducing delirium rates and length of stay for hospitalized adults. Our nurse-driven workflow included five evidence-based daytime "sunrise" interventions (patient room lights on, blinds up, mobilization/out-of-bed, water within patient's reach and patient awake) and five nighttime "turndown" interventions (patient room lights off, blinds down, television off, noise reduction and pre-set bedtime). Interventions were also chosen because fidelity could be quickly monitored twice daily without patient interruption from outside the room. To evaluate the workflow, we used an interrupted time series study design between 06/01/17 and 05/30/22 to determine if the workflow significantly reduced the unit's delirium rate and average length of stay. Our workflow is feasible to implement and monitor and initially significantly reduced delirium rates but not length of stay. However, the reduction in delirium rates were not sustained following the emergence of the COVID-19 pandemic.
To determine if B-natriuretic peptide (BNP), handheld ultrasound, and echo interpretation was an accurate and reliable screening for stage B heart failure.One hundred and forty-five indigent diabetic patients were prospectively enrolled, and their BNP levels were measured. Each patient underwent a handheld echo.BNP was correlated with ejection fraction, but not with diastolic dysfunction. The area under the receiver-operator characteristic was 0.77. Kappa statistics for reliability in interpreting handheld echoes was 1.0.Results from this study suggested that BNP may be able to serve as a reliable screening tool for stage B heart failure in diabetic populations. Because BNP is an inexpensive blood test, it could be incorporated into the congestive heart failure diagnostic algorithm to determine which patients need imaging studies, namely echocardiography. Handheld echocardiography had interobserver reliability and is a promising alternative screening method.
Introduction: Nonalcoholic fatty liver disease (NAFLD) is increasing worldwide with a prevalence ranging from 5% to 28% in India. It is a common cause of chronic liver disease and can lead to complications including cirrhosis and portal hypertension. NAFLD and insulin-resistant states such as obesity, type 2 diabetes, and prediabetes are interlinked. We studied the role of diet, dyslipidemia, and glycemia in the genesis of NAFLD in patients with prediabetes. Methods: This case–control study was done in 86 prediabetic subjects availing the services of a medical college hospital. Cases of NAFLD were diagnosed and categorized by severity by ultrasonogram. Symptoms, demographic profile, dietary history by 24 h recall method, anthropometry, liver function tests, lipid profile, and blood glucose were recorded. Results: Cases of NAFLD were found to have higher fat consumption and lower carbohydrate and protein in their diet. Fatigue and right hypochondriac pain were common symptoms among the cases, and their mean body mass index (27.2 kg/m 2 ) was higher. When compared with prediabetic controls, cases of NAFLD had higher mean systolic and diastolic blood pressures, as well as impaired lipid profile and postprandial hyperglycemia. Conclusion: Obesity, dyslipidemia, and specific dietary patterns predispose patients with prediabetes to develop NAFLD. Additionally, postprandial hyperglycemia is associated with NAFLD. Thus, targeting postprandial hyperglycemia in patients with prediabetes may retard the development of NAFLD.
While colorectal cancer (CRC) incidence and mortality rates have declined slightly over the past decade, there remain marked differences by ethnicity. Our aim was to investigate ethnic differences in occurrence, clinical presentation and outcome of CRC at a tertiary university center that serves a predominantly Hispanic population.Prospectively collected data from the tumor registry on patients diagnosed with colorectal cancer from 1985 through 2001 was examined. Age at diagnosis, mode of presentation, sex, tumor location, ethnicity, TNM stage, and survivals were assessed and ethnic differences were sought.Records from 453 patients with CRC were reviewed. There were 296 (65%) patients that were Hispanics, 112 (25%) non-Hispanic Whites, 37 (8%) African Americans, and 8 (2%) of other or unknown ethnicity. Compared with non-Hispanic Whites, Hispanics presented at a younger age (58.5 +/- 14 versus 53.6 +/- 12.73, respectively; P < 0.01), with a significantly greater incidence of stage IV disease (19% versus 32%, respectively; P = 0.02). They had significantly poorer age-adjusted survival (median survival of 92 months for <55 years and 77 months for >55 years versus 48 months for <55 years and 48 months for >55 years, respectively; adjusted log rank P = 0.045). There were no differences in tumor location, mode of presentation or adjuvant treatment received.Hispanic patients with CRC in our catchment area present at a younger age with more metastatic disease and have a poorer survival than non-Hispanic Whites. Modification of screening criteria and treatment paradigms may be required for Hispanics.
