Mercy Medical Center - Wednesday, 12:30 p.m. - Winter Room

12 Albert Yuzpe, MD, Co-Founder and Co-Director, Genesis Family Centre, Vancouver, BC; Professor Emeritus, The University of Western Ontario, London, ON.

McCleary Center - Friday, 8:00 a.m.

14 Darin Signorelli, MD, Assistant Professor of Clinical Psychiatry, University of Southern California Keck School of Medicine, Los Angeles, CA.

Tumor Boards

Mercy Medical Center - Tuesday, 12:00 noon
St. Alphonsus Regional Medical Center - Friday, 7:00 a.m.
Breast Care Panel - Saint Alphonsus RMC - Tuesday, 7:00 a.m.
St. Luke's Regional Medical Center - Tuesday, 12:00 noon
Breast Tumor Board - St. Luke's RMC - Thursday, 7:00 a.m.
MSTI Pediatric Tumor Board - 2nd & 4th Wednesday, 12:00 noon

The following members were voted in

Provisional Membership: Kathryn McMullen, MD; Stan Hill, MD
Full Membership: John Crites, MD; Jerome Oakes, MD; Stephanie Hodson, MD

June 2004

 2 Primary Prevention of Suture Related Sharps Injuries and Other Blood Injuries, Steve Bierman, MD
 4 Food Borne Disease, Leslie Tengelson, DVM
 9 Methamphetamine Use in Idaho, Matthew Keagan, MD
 9 The Role of Community Health Centers, Jonathan Bowman, MD (Mercy)
11 Benign Fibrotic Breast Disease: Risk Assessment, James Wolf, MD
16 Emerging Methicillin Resistant Staph Infections in the U.S., Dennis Stevens, MD
23 Pediatric Sleep Disorders, Stephan Asher, MD Brett Troyer, MD
30 National Patient Safety Goals for Pain Management, Steve Dorman, MD

The statin drugs already account for the largest prescription expenditure in the United States at about 12.5 billion dollars per year. In addition to the effects on lipid lowering other possible beneficial effects include Alzheimer's disease, multiple sclerosis, non-ischemic cardiomyopathy, and prevention of bone fractures. A generalized anti-inflammatory action has been invoked as an explanation for these other salutary effects. Now two new studies, both placebo controlled trials, have suggested that lower levels of LDL cholesterol then previously suggested 100mg cut off should be used in people with coronary artery disease. The first study by Nissen and colleagues compared atorvastatin (lipitor), pravastatin (prevacol), using 80mg doses of atorvastatin and 40mg doses of pravastatin during 18 months of drug treatment.

Atorvastatin was superior to pravastatin in terms of lipid limiting progression of atheroma. It also lowered LDL cholesterol more substantially. Cannon and associates also published a recent article using the same doses. In 4162 patients with acute coronary syndromes who were followed for a mean of 24 months, atorvastatin was superior to pravastatin with a 16% lower risk of major cardiovascular events. The benefit of atorvastatin was also evident very early, within 30 days of therapy. Mortality from all causes was reduced by 28%.

Only a fraction of patients who qualify are being treated with statin drugs. It is estimated that 36 million people in the United States should be taking these drugs but currently only 11million are being treated. Cost seems to be the main limiting issue. The 80mg pills of atorvastatin cost about $1400.00/year and one wonders if the increased doses will also result in more side effects. These drugs have been remarkably safe. These authors all believe that a more intensive lipid lowering regimen is required than is currently recommended by national guidelines. (JAMA, March 3, 2004; Vol:291, No. 9) (N ENGL J Med, April 8, 2004; 350:15)

Testosterone Replacement

Testosterone supplementation in the United States has increased substantially since the introduction of transdermal and gel preparations. This review article makes good points about the risks of therapy and recommendations for monitoring. Recently, the Institute of Medicine issued its report that concluded there was insufficient evidence that testosterone treatment benefits elderly men. Testosterone decreases gradually over a period of several decades in men. From 600ng per deciliter at 30 years of age to a mean of about 400ng at 80 years of age although there is a wide range at all ages. Decreases in bone density, muscle mass, strength, energy, and libido have all been attributed to these lower levels of testosterone. A big worry with replacement has been exacerbation of testosterone dependent diseases to which elderly men are prone, such as prostate cancer, BPH, erythrocytosis, and perhaps sleep apnea.

Peter Snyder, M.D. makes several suggestions in an accompanying perspective. One, the elderly male can be considered hypogonandal when his early morning serum total testosterone is consistently below 200ng per deciliter in early morning testing. Men should be monitored carefully for possible exacerbation of BPH and prostate cancer. As is true with much of what we do in medicine, clinicians need to remember, "First, do no harm." (N Engl J Med, January 29, 2004, 350;5)

John J. Mohr, M.D.