The Medical journal of Australia
-
Comparative Study
Global trends in testosterone prescribing, 2000-2011: expanding the spectrum of prescription drug misuse.
To provide the first multinational survey of temporal trends in testosterone prescribing, given that anecdotal evidence indicates that it is increasing in some countries, including Australia. ⋯ In the absence of any new indications, off-label testosterone prescribing has increased in most countries in 2000-2011, especially over the last half of the period. The increased testosterone prescribing appears to be primarily for older men and driven by clinical guidelines that endorse testosterone prescribing for age-related functional androgen deficiency (andropause). By eliminating the fundamental distinction between pathological and functional androgen deficiency, these guidelines tacitly promote increased testosterone prescribing, bypassing the requirement for high-quality clinical evidence of safety and efficacy and creating dramatic increases in prescription of testosterone products.
-
Poor sleep imparts a significant personal and societal burden. Therefore, it is important to have accurate estimates of its causes, prevalence and costs to inform health policy. A recent evaluation of the sleep habits of Australians demonstrates that frequent (daily or near daily) sleep difficulties (initiating and maintaining sleep, and experiencing inadequate sleep), daytime fatigue, sleepiness and irritability are highly prevalent (20%-35%). ⋯ While large, these costs were for sleep disorders alone. Additional costs relating to inadequate sleep from poor sleep habits in people without sleep disorders were not considered. Based on the high prevalence of such problems and the known impacts of sleep loss in all its forms on health, productivity and safety, it is likely that these poor sleep habits would add substantially to the costs from sleep disorders alone.
-
Obstructive sleep apnoea (OSA) determined by polysomnography is highly prevalent, affecting about 25% of men and 10% of women in the United States, although most have few or no symptoms. Symptomatic moderate to severe OSA has major health implications related to daytime sleepiness, such as increased accidents, altered mood and loss of productivity in the workplace. Severe OSA may increase the risk of cardiovascular disease independent of daytime sleepiness. ⋯ However, these services may not always be easy to access. Controlled studies have shown that patients with a high pretest probability of symptomatic, moderate to severe OSA can be managed well in primary care, or by skilled nurses with appropriate medical backup, using simplified ambulatory models of care. The future of sleep apnoea assessment and management will likely include models of care that involve early referral to specialists of patients with complex or atypical presentations, and an upskilled and supported primary care workforce to manage symptomatic, uncomplicated, high pretest probability disease.
-
Obstructive sleep apnoea (OSA) is a potential cause of systemic hypertension in young and middle-aged people, and treatment helps reduce blood pressure in some patients. Severe OSA (apnoea-hypopnoea index [AHI] > 30/h) is strongly associated with increased mortality, stroke and cardiovascular disease in middle-aged populations. The cardiovascular risk from moderate OSA (AHI, 15-30/h) is uncertain, particularly if the oxygen desaturation index is low, although the data suggest an increased risk for stroke (particularly in men). ⋯ Current, ongoing randomised controlled trials will inform whether OSA is a reversible cardiovascular risk factor within the next 5 years. Patients with cardiovascular disease, stroke, diabetes, obesity or poorly controlled hypertension are at high risk of OSA and should be questioned for symptoms of OSA, which, if present, may warrant further investigation and treatment. Weight loss has an unpredictable effect on OSA severity, but is independently beneficial for symptoms and metabolic health in OSA patients and is recommended for all overweight and obese OSA patients.