Mary Armitage

Experience with transdermal testosterone replacement therapy for hypogonadal men

None of the existing options for long‐term testosterone replacement therapy (TRT) for hypogonadal men are ideal. Depot replacement at frequent intervals and implants are effective but invasive and inconvenient for the patient. Oral therapy results in poor hormone levels. Both are associated with undesirable metabolic changes. A transdermal formulation therefore represents a potential therapeutic advance for testosterone replacement.

Recent concerns surrounding HRT

Millions of women are treated with hormone replacement therapy (HRT) for relief of menopausal symptoms, including vasomotor flushes and sweats for which oestrogen is uniquely and highly effective. Others may continue longer‐term treatment in the hope that HRT will help to prevent chronic disease. The preservation of bone mass with continuing oestrogen therapy and reduction of subsequent risk of fracture is well established. Observational studies of the metabolic and vascular effects of oestrogens have suggested a potential benefit in reducing the risk of vascular disease, but recently published randomized controlled trials demonstrate no evidence of benefit in women with established vascular disease or in apparently healthy women. The increased risks of breast cancer and thromboembolic disease have been confirmed in these trials, with evidence of increased risk of stroke. Observational data suggest there may be a small increased risk of ovarian cancer associated with longer‐term use of HRT. The premature termination of one arm of the Womens Health Initiative randomized controlled trial caused concern among patients, doctors and pharmaceutical companies. There are difficulties in extrapolating the results from trials using a specific HRT product to advise women on the wide range of other hormone products, doses, combinations and routes of administration. However, in the absence of evidence that other products are safer, the data suggest that for many women the risks associated with long‐term use of HRT outweigh the benefits. There are nonhormonal strategies for the prevention and treatment of osteoporosis. HRT is not, and has never been, licensed in the UK for the prevention or treatment of vascular disease, and the data suggesting potential benefit should now be regarded as biased. The absolute incidence of an adverse event is low, and the risk in an individual woman in a single year is very small, but the risks are cumulative over time with long‐term use. The risk–benefit balance of each woman needs regular reappraisal with continued use.

Prolactinoma presenting in identical twins with multiple endocrine neoplasia type 1

Multiple endocrine neoplasia type one (MEN 1) is characterized by tumours of the parathyroid glands, pancreatic islet cells and the anterior pituitary and follows an autosomal dominant pattern of inheritance. We report identical twins born to a family known to have the MEN 1 syndrome. The twins were identical until puberty. The first twin underwent puberty normally; the second, however, suffered an early pubertal arrest and was subsequently found to have a prolactinoma. Both were also subsequently shown to have primary hyperparathyroldism. Genetic studies have since confirmed the twins identical for the affected haplotype and show that this is inherited from the father who also has MEN 1. The gene for MEN 1 has now been localized to the long arm of chromosome 11. The current hypothesis is that expression of the syndrome involves two separate genetic mutations. The first mutation is inherited and thus present in all cells but the tumour manifests itself in the endocrine tissue only after a second mutation that represents ellmination of the normal allele. In the case described the twins are proven genetically identical. The marked phenotypic difference between the two must, by inference, represent a second somatic mutation and is further supportive evidence of the two‐mutation model of tumour expression.

A single generic multi-source feedback tool for revalidation of all UK career-grade doctors: does one size fit all?

Background: The UK Department of Health is considering a single, generic multi-source feedback (MSF) questionnaire to inform revalidation. Method: Evaluation of an implementation pilot, reporting: response rates, assessor mix, question redundancy and participants’ perceptions. Reliability was estimated using Generalisability theory. Results: A total of 12,540 responses were received on 977 doctors. The mean time taken to complete an MSF exercise was 68.2 days. The mean number of responses received per doctor was 12.0 (range 1–17) with no significant difference between specialties. Individual question response rates and participants’ comments about questions indicate that some questions are less appropriate for some specialities. There was a significant difference in the mean score between specialities. Despite guidance, there were significant differences in the mix of assessors across specialties. More favourable scores were given by progressively more junior doctors. Nurses gave the most reliable scores. Conclusions: It is feasible to electronically administer a generic questionnaire to a large population of doctors. Generic content is appropriate for most but not all specialties. The differences in mean scores and the reliability of the MSF between specialties may be in part due to the specialty differences in assessor mix. Therefore the number and assessor mix should be standardised at specialty level and scores should not be compared across specialties.

An exception to the rule: ectopic ACTH production from functional neuroendocrine tissue in an ovarian dermoid cyst.

Ectopic ACTH production accounts for 15% of Cushing’s syndrome presentations and is characterized by the presence of an excess of ACTH precursors. However in the case presented here ectopic ACTH production was from functional pituitary tissue within an ovarian dermoid cyst. Endocrine investigations showed that the problem behaved more like pituitary-dependent Cushing’s disease and this is discussed. Furthermore, this case is one of familial dermoid cysts, another unusual phenomenon.

Modernising Medical Careers: The need to isolate myths from facts

M odernising Medical Careers (MMC) means different things to different people; some would consider that it covers a multitude of sins. Yet in the determination and haste to damn MMC, it is easy to confuse changes to the delivery and to the structure of postgraduate medical education with the selection and recruitment to training posts and to the IT infrastructure that underpinned the electronic application service, Medical Training Application Service (MTAS). It is also easy to forget that previously there were very significant problems with postgraduate medical training for senior house officers, which led to the policies that aimed to improve training and career structure for junior doctors.

General medicine in the UK — back stage or centre stage?

Internal medicine, in the UK as well as in the rest of Europe, is in a state of flux. The service has evolved so that the management of acute medical emergencies increasingly dominates the practice of internal medicine, with most outpatient work being dealt with by specialists. As a result, much of the activity of consultant physicians is focused on the delivery of care rather than on the training aspects of internal medicine. Nevertheless, all medical specialists in the UK do pass through a rigorous period of internal medicine during their early training, and there is now increasing emphasis on ensuring that these skills are maintained by practising physicians.

Testosterone hormone replacement and its alternatives

The use of testosterone replacement is increasing and this trend is expected to continue; due in part to the ageing population of the developed world. The production of this androgen is described to emphasise the diversity of possible therapeutic interventions. Current therapies are reviewed briefly to illustrate how the developments claimed in the patent literature may improve patient acceptability as well as increasing therapeutic testosterone levels safely and physiologically. The patents divide into novel androgens, or androgen-esters available to be administered via several different routes, including oral treatment. Following on from this, patents to improve transdermal testosterone delivery are considered with novel reservoir and matrix patches as well as new enhancers and gels. In recent years alternative methods for increasing testosterone concentrations have been patented. These include direct stimulation of androgen production, displacement of testosterone from sex hormone binding globulin, anti-oestrogens and non-steroidal androgen agonists. Finally, claims for novel androgen replacement in women are described, as androgens have been shown to improve specific symptoms of the climacteric.

The nursing process

and it is even more disturbing that some nurses themselves seem unsure of its aims and application. Many of the nurses concerned with the documentation are the most junior and those in training, and it is not surprising that a checklist mentality has taken hold. In a wider context the teaching of nurses has slowly changed. Many of those teaching no longer hold clinical posts and their entry on to a ward may be seen as an unwelcome interruption of an efficient routine. Similarly nurses in training may feel that much of the time spent in school is less relevant to their job at the bedside. We would urge a pause in the development of the nursing process-let its benefit for patient care be adequately proved before it is wholeheartedly adopted.