The assessment of vascular risk in men with erectile dysfunction: the role of the cardiologist and general physician.

Erectile dysfunction (ED) and cardiovascular disease (CVD) share risk factors and frequently coexist, with endothelial dysfunction believed to be the pathophysiologic link. ED is common, affecting more than 70% of men with known CVD. In addition, clinical studies have demonstrated that ED in men with no known CVD often precedes a CVD event by 2-5 years. ED severity has been correlated with increasing plaque burden in patients with coronary artery disease. ED is an independent marker of increased CVD risk including all-cause and especially CVD mortality, particularly in men aged 30-60 years. Thus, ED identifies a window of opportunity for CVD risk mitigation. We recommend that a thorough history, physical exam (including visceral adiposity), assessment of ED severity and duration and evaluation including fasting plasma glucose, lipids, resting electrocardiogram, family history, lifestyle factors, serum creatinine (estimated glomerular filtration rate) and albumin:creatinine ratio, and determination of the presence or absence of the metabolic syndrome be performed to characterise cardiovascular risk in all men with ED. Assessment of testosterone levels should also be considered and biomarkers may help to further quantify risk, even though their roles in development of CVD have not been firmly established. Finally, we recommend that a question about ED be included in assessment of CVD risk in all men and be added to CVD risk assessment guidelines.

Toward a new 'EPOCH': optimising treatment outcomes with phosphodiesterase type 5 inhibitors for erectile dysfunction.

Despite the marked adverse impacts of erectile dysfunction (ED) on quality of life and well-being, many patients (and/or their partners) do not seek medical attention for this problem, do not receive treatment or discontinue such treatment even when it has effectively restored erectile responses to sexual stimulation. Phosphodiesterase type 5 (PDE5) inhibitors are considered first-line therapies for men with ED. To help physicians maximise the likelihood of treatment success with these agents, we conducted an English-language PubMed search of articles involving approved PDE5 inhibitors dating from 1 January 1998 (the year in which sildenafil citrate was introduced), through 31 August 2008. In addition to sildenafil, tadalafil and vardenafil, search terms included 'adhere*', 'couple*', 'effect*', 'effic*', 'partner*', 'satisf*', 'succe*' and 'treatment outcome.' Based on our analysis, physician activities to promote favourable treatment outcomes may be captured under the mnemonic 'EPOCH': (i) Evaluating and educating patients and partners to ensure realistic expectations of therapy; (ii) Prescribing a treatment individualised to the couple's lifestyle needs and other preferences; (iii) Optimising treatment outcomes by scheduling follow-up visits with the patient to 'fine-tune' dosages and revisit key educational messages; (iv) Controlling comorbidities via lifestyle counselling, medications and/or referrals and (v) Helping patients and their partners to meet their health and psychosocial needs, potentially referring them to a specialist for other forms of therapy if they are not satisfied with PDE5 inhibitors.

Benign prostatic hyperplasia evaluation, treatment and association with sexual dysfunction: practice patterns according to physician specialty.

AIMS: Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) are a common problem in ageing men and are accompanied by sexual dysfunction (SD) in 40-70% of men evaluated in large-scale epidemiological studies. One year after the 2003 American Urological Association (AUA) guideline on BPH management was published, a survey of US urologists (UROs) and primary care physicians (PCPs) was conducted to ascertain physician knowledge of the AUA guideline and practice patterns regarding LUTS/BPH diagnosis, treatment and association with SD. METHODS: A 19-question qualitative survey, sponsored by the American Foundation of Urologic Disease, was mailed April 2004 to 7500 UROs and 17,500 PCPs, with responses collected until May 2004. RESULTS: A total of 788 surveys were returned (437 UROs; 351 PCPs). Only 62% of PCPs were aware of and only 41% of PCPs used the AUA-Symptom Index/International Prostate Symptom Score (AUA-SI/IPSS) to assess LUTS compared with 97% and 81% of UROs respectively. Alpha-blocker monotherapy was the treatment of choice for both UROs and PCPs. Compared with UROs, PCPs reported higher rates of SD in association with LUTS or BPH (37% vs. 27%) and BPH pharmacotherapy (27% vs. 21%). UROs and PCPs reported higher rates of SD side effects [ejaculatory dysfunction (EjD) and erectile dysfunction (ED)] for tamsulosin (EjD: UROs 22%, PCPs 12%; ED: UROs 7%, PCPs 10%) and doxazosin (EjD: UROs 14%, PCPs 10%; ED: UROs 7%, PCPs 12%) than for alfuzosin (EjD: UROs 6%, PCPs 4%; ED: UROs 4%, PCPs 5%). CONCLUSIONS: The results suggest that many PCPs are not using the AUA-SI/IPSS to assess LUTS in their ageing male patients. Both UROs and PCPs appear to be underestimating the prevalence of SD in men with LUTS/BPH relative to prevalence rates reported in large-scale epidemiological studies.

Efficacy of tadalafil in the treatment of erectile dysfunction in hypertensive men on concomitant thiazide diuretic therapy.

Many men with erectile dysfunction (ED) have hypertension as a comorbid condition. Recent guidelines recommend thiazide diuretics as first-line therapy for hypertension. We analyzed data from 14 randomized, double-blind, placebo-controlled trials (N=2501) to evaluate the efficacy of tadalafil 20 mg for the treatment of ED in men on thiazides. Of the 2501 patients, 163 were on concomitant thiazides (116 tadalafil/47 placebo) and 159 (98%) were reported to have hypertension. The primary efficacy measures were mean change from baseline in the international index of erectile function (IIEF) erectile function (EF) domain and the proportion of 'yes' responses to sexual encounter profile (SEP) Questions 2 and 3. The tadalafil group showed a significantly (P<0.001) greater mean baseline to endpoint improvement on all efficacy outcome measures compared to placebo-treated patients regardless of concomitant thiazide use. More importantly, the responses to tadalafil were similar regardless of concomitant thiazide use. Additionally, responses to tadalafil were comparable between thiazide and nonthiazide users regardless of baseline ED severity (P>0.05).

Integrating erectile dysfunction treatment into primary care practice.

Erectile dysfunction (ED) is a highly prevalent medical disorder. Nearly 1 of 3 men in the United States between the ages of 18 and 59 years report dissatisfaction with some aspect of their sexual function. These problems contribute to anxiety, depression, loss of self-esteem, and diminished quality of life. The availability of sildenafil, the first safe and effective oral agent for ED, has greatly increased the number of men seeking treatment and shifted much of the management of ED to primary care physicians. As a result, primary care physicians now need to add questions about sexual functioning and satisfaction with sex to their initial patient workups. Patients with ED can be treated by the primary care physician or referred to mental health professionals, endocrinologists, urologists, or sex therapists, depending on the problem presented. First-line treatments that can be easily prescribed and recommended by primary care clinicians include sildenafil, counseling, lifestyle changes, medication changes, and vacuum-constriction devices. The responsibilities of treating patients with ED include educating the patient about sexually transmitted diseases, providing general sex education and counseling to the patient and his partner, and providing a treatment that is appropriate for the cause of the problem. The rewards of treatment will be a happier and more functional patient, an enhanced physician-patient relationship, and great professional satisfaction.

Structuring a home visit program for residents.

Home assessment visits in which a family practice resident accompanied by a social worker and a specially trained nurse go to a patient's home have been a part of the curriculum for three years. A specific format has been developed for these visits. The trainees' initial positive views about home assessment visits were maintained after the visits with improved understanding of the impact of environmental, familial, and social factors on patient health. The efforts and effects of the nonphysician health care providers in home visits were clarified. Clearly, residents can appreciate and benefit from a well-structured home visit program.

Sarcoidosis of the liver: evaluation with multiple imaging modalities.

Although sarcoidosis of the liver is common pathologically, imaging findings are extremely rare, because the noncaseating granulomas are usually not macroscopic and thus do not produce focal abnormalities. We present 2 cases of liver sarcoidosis with focal findings on computed tomography, magnetic resonance imaging, nuclear scanning, and ultrasonography. Imaging characteristics, which may facilitate making the diagnosis, are presented.

The initial assessment of the HIV-infected patient.

The initial assessment of the patient with HIV disease requires clinical staging, identification of HIV-related and nonrelated illness, discussion of specific psychosocial issues, initiation of the process of patient education, and initiation of a sustained partnership between patient and clinician. The clinical content of the assessment depends on knowledgeable history-taking, focused physical examination, and specific laboratory tests. Partnering increases the likelihood of early recognition of important signs and symptoms and the institution of appropriate therapeutic measures. Successful and satisfying clinician-patient relationships help produce better patient outcomes.

Initial clinical assessment and management of HIV infection.

Management of HIV infection by the primary care physician can be easily integrated into the usual practice setting. The physician who understands the epidemiology of HIV disease, stays current with basic therapeutic concepts, and knows the patient and his or her living environment is in the best position to help the HIV-infected individual have a constructive and fulfilling life. When the primary care physician has a network of appropriate specialists for consultation and has appropriately integrated office and community-based nonmedical professionals into patient care, the health care team is complete.

Angioimmunoblastic lymphadenopathy: common symptoms, uncommon diagnosis.

After five months of treatment for what was believed to be tuberculosis, a 49-year-old woman had recurrence of high spiking fever, lymphadenopathy, and malaise along with an intermittent maculopapular rash. Other findings were a positive Coombs test, iron deficiency, elevated gamma globulin levels, polyclonal gammopathy, and hepatosplenomegaly. Biopsy of a cervical lymph node revealed an angioblastic pattern consistent with angioimmunoblastic lymphadenopathy. Review of biopsy material obtained six months previously showed the same changes. Antituberculosis therapy was discontinued, and a regimen of prednisone and iron replacement was begun. The patient did well initially; when symptoms returned, they were controlled by adding azathioprine to the regimen for steroid-sparing effect. However, serologic abnormalities returned and within a few months, symptoms exacerbated; despite intensive medical therapy, the patient died. Angioimmunoblastic lymphadenopathy is a recently recognized disorder with a usually progressive course. No treatment has yet been established as effective, and death usually occurs within one year after diagnosis.

Promotion of family enrollment in an urban family practice residency program.

Although a basic goal of family practice is to provide care for all members of the family, few studies have been done to test the ease of accomplishing this goal. At the Downstate Medical Center Department of Family Practice in Brooklyn, New York, an attempt was made to increase family enrollment by introducing several educational interventions directed at patients and resident physicians. Family enrollment levels were documented during a study period from June 1981 to September 1982, and again in June 1984. Both before and after the intervention efforts, family enrollment levels remained the same. It was concluded that the educational interventions used were unsuccessful in both short-term and long-term follow-up. Only one subgroup that participated in a specific educational intervention (patient orientation groups) showed an increase in family enrollment.

Impact of an educational initiative on applied knowledge and attitudes of physicians who treat sexual dysfunction.

A randomized, blinded, multicenter, controlled study was undertaken to assess the impact of a multiyear continuing medical education (CME) initiative on physician knowledge and behavior in the treatment of erectile dysfunction (ED). The objective of this study was to assess the efficacy of CME and compare applied knowledge and attitude scores of participants in the Consortium for Improvement in Erectile Function (CIEF), to non-CIEF participants. Subjects were selected randomly and contacted anonymously, by mail, email and fax and requested to enroll in this study. A blinded, validated questionnaire and series of standardized patient (SP) case studies and attitude questions were given to CIEF participants, defined as those who showed an interest in learning more about ED and who took at least one CME-certified program on ED from the CIEF website and non-CIEF participants, defined as those who showed interest in learning more about ED and who took at least one CME-certified program on ED from any organization other than CIEF. The primary outcome was a comparison of subjects' scores who participated in at least one CIEF program to non-participants in CIEF programs. Subjects were also compared based on SP case scores, attitude scores, specialty, years in practice, age and gender. Answers were ranked from best to worst and assigned a corresponding value of 10...3, 2, 1 and 0 (10 being the best), assuming that there may be more than one correct answer to each question in clinical practice. SAS version 9.1 analysis of variance model was used by an independent consultant. A total of 120 physicians completed the questionnaire: 87 urologists (UROs) and 33 primary care physicians (PCPs). UROs scored higher on SP cases compared with PCPs (P=0.0039); however, as a result of participating in CIEF programs, PCPs trended toward more comparable scores to UROs; P=0.23 for SP case 2 that was clinically less complex and P=0.19 for SP case 3 that was more complex. In the other two cases, the gap was reduced; however, UROs scored better than PCPs. PCPs in CIEF (n=23) had significantly higher SP case scores compared with non-CIEF PCPs (n=10); 216.6 vs 191.0, respectively (P=0.0437). PCPs in CIEF also showed a significantly greater level in mean attitude scores compared with UROs, 10.82 vs 8.15, respectively (P<0.0001). Both PCPs and UROs scored higher after participating in CIEF ED educational programs than those clinicians who participated in non-CIEF ED educational programs. In addition, clinicians participating in more CIEF programs scored higher than those participating in fewer CIEF programs. As expected, UROs consistently scored better than PCPs, indicating a higher baseline level of knowledge base about ED. However, this educational gap was significantly reduced in PCPs who participated in CIEF programs. The study demonstrated that PCPs who took more CIEF courses were almost as knowledgeable as UROs on the subject of ED. Longitudinal, disease-specific CME initiatives are valuable in that they positively impact the knowledge and thus the behavior of participating physicians, potentially conferring clinical benefits toward patient outcomes.

Identification and diagnosis of premature ejaculation.

In sexual health surveys, premature ejaculation (PE) is frequently the most common condition reported by men. Men with symptoms of PE often report a significant impact of the condition on their lives, experiencing personal distress and interpersonal difficulty related to their condition. Unfortunately, PE is highly ignored by the patients and the healthcare community. Most of the men do not seek medical treatment for their PE. Survey data indicate that men are reluctant to discuss sexual issues with physicians and that the physicians generally do not initiate discussions of such issues. The aim of this article was to discuss the prevalence of this condition and the impact that it has on the patient as well as on the partner. We will address the characteristics of PE, discuss interview techniques to identify the condition, and outline ways to differentiate PE from erectile dysfunction. It is our conclusion that the recognition and diagnosis of sexual dysfunctions may subsequently lead to treatment opportunities, which, in turn, may improve the quality of life for patients with such disorders.

Efficacy and safety of alfuzosin 10 mg once daily in the treatment of symptomatic benign prostatic hyperplasia.

Benign prostatic hyperplasia (BPH) is a common disorder in ageing men. Patients with BPH often present with bothersome irritative and obstructive lower urinary tract symptoms -- urgency, frequency, nocturia, feeling of insufficient bladder emptying and weak or intermittent flow. alpha(1)-Blockers are the most frequently prescribed oral medications for the first-line treatment of the symptoms associated with BPH. Alfuzosin is a uroselective alpha(1)-blocker that relaxes the smooth muscle of the bladder neck and prostate gland to alleviate BPH symptoms. A pooled analysis of three phase III trials confirmed that treatment with alfuzosin 10 mg q.d. significantly improves the peak urinary flow rate and symptom severity compared with placebo treatment. Unlike some other alpha(1)-blockers, alfuzosin 10 mg q.d. is associated with a low incidence of sexual and vasodilatory side effects. Based on the clinical trials reviewed, alfuzosin 10 mg q.d. is an effective and well-tolerated treatment for the urinary symptoms associated with BPH.

Psychosocial issues in symptomatic HIV infection.

Psychosocial issues are a major factor in the quality of life of a patient with advanced human immunodeficiency virus infection. To provide effective, supportive care, the physician must assess the patient's psychosocial needs, with an understanding of the patient's sociocultural background. Good communication and a multidisciplinary team approach are essential aspects of successful management. Unconditional emotional support and both verbal and nonverbal expressions of caring increase patient compliance and comfort. Appropriate treatment of neuropsychiatric syndromes and debilitating physical symptoms also add significantly to the patient's quality of life. Most importantly, the patient must be given the opportunity to be an active participant in decisions about treatment and lifestyle.

HIV-infected patients: a primary care challenge.

Ambulatory management of patients infected with human immunodeficiency virus (HIV) is rapidly becoming a necessity for both financial and staffing reasons. Many primary care physicians are anxious about providing care for these patients, perhaps because of inadequate clinical training or because of perceptions of personal and employee risk. The willingness of physicians to care for HIV-infected patients may be increased by the clarification of issues of risk and the institution of effective, ongoing physician education programs. It is also important for physicians to understand their own anxieties and emotions. Because medicine is viewed as a profession that provides care for all segments of the population, physicians have an obligation to accept an appropriate level of risk in caring for HIV-infected patients.

Diagnosis and management of systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is not a rare disease. There are several common clinical signs which should alert the physician to a possible diagnosis of SLE and which should condition him to look for specific clinical and laboratory findings. In addition to simple screening tests, useful procedures include a search for antinuclear antibodies, lupus erythematosus (LE) cells, anti-DNA antibodies and low serum complement. Management is determined by the type of course encountered but most patients will do well under the care of their family physician.