Are SERMs safe and effective for the treatment of hypogonadism in men?

YES. For both normal-weight and obese men with low testosterone levels and hypogonadal symptoms, selective estrogen receptor modulators (SERMs), such as clomiphene citrate (CC) and enclomiphene citrate (EC), appear to be effective and safe for improving serum testosterone levels (strength of recommendation [SOR]: C, disease-oriented outcomes from randomized controlled trials [RCTs] and cohort studies). Studies also show that symptom improvement is comparable to that with exogenous testosterone replacement and similar to eugonadal men (SOR: B, patient-oriented outcomes from retrospective cohort studies).

Elevated Transaminases with Topical Diclofenac: A Case Report.

Drug-induced liver injury (DILI) has been described with numerous nonsteroidal anti-inflammatory drugs (NSAIDs). Oral diclofenac has been associated with DILI more frequently than other NSAIDs and requires periodic monitoring of liver transaminases and judicious consideration of clinical signs and symptoms of hepatotoxicity. Here we describe a case in which elevated liver transaminases in a 79-year-old female returned to normal following discontinuation of topical diclofenac 1% gel. Using a widely accepted drug reaction causality instrument, a rating of "definite" was assigned given the temporal sequence of drug exposure and transaminase changes. Further study is warranted to better guide prescribing of topical NSAIDs.

Treating Painful Diabetic Peripheral Neuropathy: An Update.

Painful diabetic peripheral neuropathy occurs in approximately 25% of patients with diabetes mellitus who are treated in the office setting and significantly affects quality of life. It typically causes burning pain, paresthesias, and numbness in a stocking-glove pattern that progresses proximally from the feet and hands. Clinicians should carefully consider the patient's goals and functional status and potential adverse effects of medication when choosing a treatment for painful diabetic peripheral neuropathy. Pregabalin and duloxetine are the only medications approved by the U.S. Food and Drug Administration for treating this disorder. Based on current practice guidelines, these medications, with gabapentin and amitriptyline, should be considered for the initial treatment. Second-line therapy includes opioid-like medications (tramadol and tapentadol), venlafaxine, desvenlafaxine, and topical agents (lidocaine patches and capsaicin cream). Isosorbide dinitrate spray and transcutaneous electrical nerve stimulation may provide relief in some patients and can be considered at any point during therapy. Opioids and selective serotonin reuptake inhibitors are optional third-line medications. Acupuncture, traditional Chinese medicine, alpha lipoic acid, acetyl-l-carnitine, primrose oil, and electromagnetic field application lack high-quality evidence to support their use.

Beware of the Beetle: A Case Report of Severe Vesicating Dermatitis.

INTRODUCTION: Outbreaks of Paederus dermatitis have been documented worldwide. A case of Paederus dermatitis from Ethiopia is presented to highlight the importance of this clinical entity in the deployed setting. CASE PRESENTATION: A 31-year-old male presented with a 3- day history of scattered areas of a purulent, vesicating erythematous rash to his mid-back and neck. The largest of these measured 5 × 7 cm with erythematous borders and an erosive center. One to 2 days prior, 15 troops reported similar and less severe vesicating lesions to their extremities and backs. All patients participated in the same outdoor recreational event. A survey of the event's location revealed signs of the Paederus beetle. DISCUSSION: Although a known phenomenon, there are no literature reports of Paederus dermatitis within AFRICOM. Crushing the Paederus beetle against the skin causes an intense rash because of paederin in the hemolymph. Most present with typical linear lesions likely caused by brushing off the beetle from the skin. Fortunately, patients respond favorably to topical steroid treatment. CONCLUSION: Paederus beetle exposure in the deployed setting can impact force health. Increased awareness among providers and personnel should mitigate potential exposure and limit the morbidity associated with this beetle.

When the solution is part of the problem: problem solving in elderly suicide attempters.

OBJECTIVES: Depression, loss, and physical illness are associated with suicide in the elderly. However, the nature of individual vulnerability remains poorly understood. Poor problem solving has been suggested as a risk factor for suicide in younger adults. Unresolved problems may create an accumulation of stressors. Thus, those with perceived deficits in problem-solving ability may be predisposed to suicidal behavior. To test this hypothesis, we investigated whether elderly suicide attempters perceived their problem solving as deficient. METHODS: Sixty-four individuals aged 60 and older participated in the study including depressed suicide attempters, depressed non-attempters, and non-depressed controls. The social problem solving inventory-revised: short-version was used to measure participants' perceived social problem solving, assessing both adaptive problem-solving dimensions (positive problem orientation and rational problem solving) and dysfunctional dimensions (negative problem orientation, impulsivity/carelessness, and avoidance). RESULTS: Depressed elderly who had attempted suicide perceived their overall problem solving as deficient, compared to non-suicidal depressed and non-depressed elderly. Suicide attempters perceived their problems more negatively and approached them in a more impulsive manner. On rational problem solving and avoidant style sub-scales, suicide attempters did not differ from non-suicidal depressed. However, both depressed groups reported lower rational problem solving and higher avoidance compared to non-depressed controls. CONCLUSIONS: A perception of life problems as threatening and unsolvable and an impulsive approach to problem solving appear to predispose vulnerable elderly to suicide attempts.