Efficacy and Safety of Testosterone Treatment in Men: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians.

Background: Testosterone treatment rates in adult men have increased in the United States over the past 2 decades. Purpose: To assess the benefits and harms of testosterone treatment for men without underlying organic causes of hypogonadism. Data Sources: English-language searches of multiple electronic databases (January 1980 to May 2019) and reference lists from systematic reviews. Study Selection: 38 randomized controlled trials (RCTs) of at least 6 months' duration that evaluated transdermal or intramuscular testosterone therapies versus placebo or no treatment and reported prespecified patient-centered outcomes, as well as 20 long-term observational studies, U.S. Food and Drug Administration review data, and product labels that reported harms information. Data Extraction: Data extraction by a single investigator was confirmed by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. Data Synthesis: Studies enrolled mostly older men who varied in age, symptoms, and testosterone eligibility criteria. Testosterone therapy improved sexual functioning and quality of life in men with low testosterone levels, although effect sizes were small (low- to moderate-certainty evidence). Testosterone therapy had little to no effect on physical functioning, depressive symptoms, energy and vitality, or cognition. Harms evidence reported in trials was judged to be insufficient or of low certainty for most harm outcomes. No trials were powered to assess cardiovascular events or prostate cancer, and trials often excluded men at increased risk for these conditions. Observational studies were limited by confounding by indication and contraindication. Limitation: Few trials exceeded a 1-year duration, minimum important outcome differences were often not established or reported, RCTs were not powered to assess important harms, few data were available in men aged 18 to 50 years, definitions of low testosterone varied, and study entry criteria varied. Conclusion: In older men with low testosterone levels without well-established medical conditions known to cause hypogonadism, testosterone therapy may provide small improvements in sexual functioning and quality of life but little to no benefit for other common symptoms of aging. Long-term efficacy and safety are unknown. Primary Funding Source: American College of Physicians. (PROSPERO: CRD42018096585).

SYMPTOMATIC PITUITARY METASTASES: TWO CASE REPORTS WITH CONTRASTING CLINICAL PRESENTATIONS.

OBJECTIVE: To report 2 interesting cases of pituitary metastasis (PM) with differing presentations, and briefly review the literature regarding the incidence, presentation, and natural history of PMs. METHODS: Case report and literature review. RESULTS: Patient 1 had known widely metastatic papillary thyroid cancer and presented with signs and symptoms of anterior pituitary dysfunction. He was found to have an undetectable AM cortisol. Further lab evaluation showed complete anterior panhypopituitarism. Pituitary magnetic resonance imaging (MRI) revealed an infiltrative pituitary lesion, which was presumed to be a meta-static lesion from his thyroid cancer. Patient 2 presented with an acute increase in urinary frequency and polydipsia. Water deprivation testing confirmed central diabetes insipidus (DI). Brain MRI showed an infiltrative pituitary lesion, which was the first sign of recurrent metastatic colon cancer. Subsequently, he developed the rapid onset of complete anterior panhypopituitarism. Review of the literature shows that when PMs produce symptoms, the most common presentation has traditionally been central DI. However, this is shifting as the incidence of anterior dysfunction and cranial nerve abnormalities is rising in more recent reviews. CONCLUSION: Central DI has traditionally been the most common presenting symptom of PM, however symptoms reflective of anterior pituitary dysfunction and cranial nerve abnormalities are being reported with increasing frequency. PM should remain in the differential in any form of pituitary dysfunction.

Interest in Family Medicine Among US Medical Students and Its Association With a Community College Academic Pathway.

BACKGROUND AND OBJECTIVES: One-third of all medical students attend a community college (CC) on their path to medical school. The objective of this study was to examine the association between CC participation and initial specialty of interest among US allopathic medical students. METHODS: We performed a national cross-sectional study of allopathic medical students who completed the 2012 Association of American Medical Colleges' Matriculating Student Questionnaire. Bivariate and logistic regression analyses were conducted. RESULTS: A total of 9,885 medical student respondents were included in the study sample, consisting of 7,035 (71%) non-CC pathway, and 2,850 (29%) CC pathway participants. CC pathway participants were more likely to express intent to specialize in family medicine (272/2,850 [10%] vs 463/7,035 [7%], P<.001), compared to those on the non-CC path. CC pathway participants had higher odds of intent to specialize in family medicine (adjusted odds ratio [AOR]=1.32; 95% CI 1.13-1.56, P<0.001), compared to those on the non-CC path. Women, independent of college pathway, were nearly two times more likely to express an intention to specialize in family medicine, and three times more likely to express an intention to specialize in pediatrics than men. CONCLUSIONS: Medical students who used a CC pathway are more likely to have intentions to specialize in family medicine, compared to those on the non-CC path.