Men＇s health is evolving

The Asian Journal of Andrology （AJA） is growing at a fast pace and becoming one of the leading journals in the field of andrology thanks to the leadership of Prof. Yi-Fei Wang, Editor-in-Chief of AJA, and the hard work of the AJA editorial staff. It was the spring of 2006 in Chicago when Ms. Dan-Qing Ren, Scientific Editor of the AJA, first approached us at the 31 st American Society of Andrology （ASA） Annual Meeting regarding publishing a special issue on men＇s health. We were honored by the invitation to be guest editors for this special issue. We discussed potential topics with many of the contributors while Ms. Qin-Zhu Zheng, Editorial Director of the AJA worked out the details and met with us at the 32nd ASA Annual Meeting in Tampa, Florida. We are very pleased to present this issue of superior articles with contributions by internationally recognized authorities.     

Osteoporosis in Men: What has Changed?

Osteoporosis in men is finally receiving some attention; it has been realized that men are more likely to die after hip fracture. Methods for screening men for osteoporosis include dual energy x-ray absorptiometry and use of fracture risk calculators such as FRAX (World Health Organization) and the Garvan nomogram. Evaluation of men will often identify secondary causes of osteoporosis as well as multiple risk factors. Alendronate, risedronate, zoledronic acid, and teriparatide are US Food and Drug Administration (FDA)—approved therapy for men. Men on androgen deprivation therapy (ADT) are at high risk for bone loss and fracture, and all the bisphosphonates have been shown to increase bone density. The new antiresorptive drug, denosumab, although FDA-approved only for postmenopausal women, has been shown in a study of men on ADT to increase bone density in spine, hip, and forearm and decrease vertebral fractures on x-ray. Thus, there is great progress in osteoporosis in men, and recognition of its importance is increasing.     

Do Men Outperform Women During Orthopaedic Residency Training?

Background

Orthopaedic surgery residency has one of the lowest percentages of women (13.1%) of all primary surgical specialties. There are many possible reasons for this, including bias during the selection process.

Questions/purposes

We therefore asked whether performance during residency might adversely bias the selection of future female orthopaedic residents by researching whether males and females perform equally in orthopaedic surgery residency.

Methods

Ninety-seven residents enrolled in our residency between 1999 and 2009; six males and one female left the program, leaving 90 residents (73 males, 17 females) as the study cohort. Resident performance was compared for OITE scores, ABOS results, faculty evaluations, and in a resident graduate survey.

Results

Males and females had similar faculty evaluations in all ACGME competency areas. Males and females had similar mean OITE scores for Years 2–5 of residency, although males had higher mean scores at Years 3 through 5. Males and females had similar mean ABOS Part 1 scores and ABOS Part 1 pass rates; however, fewer males than females took more than one attempt to pass. Males and females had similar Part 2 pass rates or attempts. For the 45 resident graduates surveyed, females pursued fellowships equally to males, worked slightly less hours in practice, and reported higher satisfaction with their career choice.

Conclusions

For the 90 residents at one residency program, we observed no differences between males’ and females’ performance. Although females pursue orthopaedic residency less frequently than males, performance during residency should not bias their future selection.     

Men不到包块的乳癌16例诊治分析

分析１６例Ｍｅｎ不到包块的乳癌的诊断和治疗。结果显示在乳腺囊性腺生病，乳腺导管内乳头状瘤早期癌变或导管内癌，乳腺派杰病和早期浸润性导管癌等均可在Ｍｅｎ不到包块期发现。乳腺局限性增厚，病理性乳头溢液，乳头糜烂，新近发生的乳头轻度回缩。乳房皮肤轻度凹陷或水肿，一侧乳癌术后的对侧乳腺有可疑质变者或更年期后又出现乳房症状者是其较早期出现的症状，需进一步进行相应检查及精确的定位活检，随访结果提示单纯乳房切除     

A Genetic Score Can Identify Men at High Risk for Prostate Cancer Among Men With Prostate-Specific Antigen of 1–3 ng/ml

Background

The diagnostic performance of a genetic score based on single nucleotide polymorphisms (SNPs) is unknown in the prostate-specific antigen (PSA) range of 1–3 ng/ml. A substantial proportion of men in this PSA span have prostate cancer (PCa), but biomarkers to determine who should undergo a prostate biopsy are lacking.

Objective

To evaluate whether a genetic risk score identifies men in the PSA range of 1–3 ng/ml who are at higher risk for PCa.

Design, setting, and participants

Men aged 50–69 yr with PSA 1–3 ng/ml and without a previous prostate biopsy were selected from the STHLM2 cohort. Of 2696 men, 49 SNPs were genotyped, and a polygenic risk score was calculated. Of these men, 860 were invited according to risk score, and 172 underwent biopsy.

Outcome measurements and statistical analysis

The risk of PCa was assessed using univariate and multivariate logistic regression analysis.

Results and limitations

PCa was diagnosed in 47 of 172 participants (27%), with Gleason sum 6 in 36 of 47 men (77%) and Gleason sum ≥7 in 10 of 47 men (21%); one man had intraductal cancer. The genetic score was a significant predictor of a positive biopsy (p = 0.028), even after adjusting for PSA, ratio of free to total PSA, prostate volume, age, and family history. There was an increase in the odds ratio of 1.60 (95% confidence interval, 1.05–2.45) with increasing genetic risk score. The absolute risk difference of positive biopsy was 19 percentage points, comparing the high and low genetic risk group (37% vs 18%).

Conclusions

A risk score based on SNPs predicts biopsy outcome in previously unbiopsied men with PSA 1–3 ng/ml. Introducing a genetic-based risk stratification tool can increase the proportion of men being classified in line with their true risk of PCa.     

Do Men and Women Fracture Bones at Similar Bone Densities?

When the World Health Organization (WHO) guidelines for the definition of osteoporosis in postmenopausal women were identified similar proposals were not developed for men as there was insufficient evidence about the relationship between bone density and fracture in men. We have therefore examined the relationship between bone density and vertebral fracture in men and women attending for assessment of possible osteoporosis. Two hundred and sixty-four women (age 64 [SD 10] years) and 37 men (age 55 [10] years) were studied. Bone density was measured in the lumbar spine and femoral neck by dual-energy X-ray absorptiometry and expressed both as bone mineral density (BMD; g/cm²) and as T-scores. In both sexes there was a sigmoid relationship between the cumulative frequency of vertebral fracture and bone density at both sites. There was a linear relationship between the log odds of fracture and bone mass for both sexes and both sites (r= 0.97–0.99; p<0.0001). The slope of these lines was significantly steeper for men than women. The BMD at which there was 50% risk of fracture was higher in men than women (0.908 vs 0.844 g/cm²). The difference between the slopes was similar when the bone mass was expressed as a T-score. However, the T-score associated with 50% prevalence of fracture was similar in the two sexes (F: −2.77 vs M: −2.60). We conclude that although there is a different relationship between bone density and fracture in the two sexes the current WHO definition of osteoporosis in postmenopausal women can be appropriately applied to men. Received: 24 February 1999 / Accepted: 12 July 1999     

The Androgen Cascade in Ageing Men: Blessing or Curse?

Dihydrotestosterone (DHT) is a dominant force in the development of the adult prostate. The action of DHT is critical in modulating the interaction of epithelial cells in the urogenital sinus mesenchyme during the organogenesis of the prostate. During adolescence, DHT is required to complete the normal growth phase of the prostate. In older men, if the response to DHT is altered, the resulting population of cells may be dominated by the transient proliferation of intermediate cells that are very sensitive to DHT for their ‘amplifying’ potential. In benign prostatic hyperplasia, these mechanisms are disturbed and the usual control of final stromal and epithelial cell mass is ineffective. The importance of the two isozymes of 5α reductase in regulating the continuing stromal:epithelial cell balance might provide a good scientific basis for moderating both pathways in an attempt to alter the clinical consequences of abnormal prostate growth.     

Estrogen Receptor Content in Malignant Breast Tumors in Men—a Review

Male breast cancer is a rare disease and clinical or epidemiological data are available from only a relatively few cases. Nonetheless, both similarities and discrepancies are apparent between breast cancer in men and women. For example, lobular and mucinous carcinomas are seldom seen in men. Tumors in men more often display neuroendocrine differentiation, with an average age at diagnosis ten years later than in women. A high proportion of breast tumors in men are estrogen receptor- positive (in this review 77%) and progesterone receptor positive (76%). Breast tumors in men often respond favorably to endocrine manipulation, including testicular ablation or antiestrogen therapy. Thus, the hormone receptors in these tumors can be functionally active and used for therapeutic intervention. This proposal has been questioned in some studies because estrogen dependent proteins are expressed to a lesser degree in men. Furthermore, men do not have a better overall breast cancer prognosis compared with women, after adjustments have been made for age and tumor stage. While the androgen receptor content has been assessed in a few studies, there are no studies on the estrogen receptor- content of breast tumors in men.     

Screening Mammography in Men with BRCA Mutations: Is There a Role?

Male breast cancer is rare, with an estimated incidence of 1.08 per 100,000 men, and a death rate less than one third of that. However, the incidence of breast cancer in men with the BRCA2 mutation is significantly higher, 7.1% before age 70 (Evans et al., J Med Genet. 2010; 47:710). Due to the low incidence of male breast carcinoma, and even lower incidence of male BRCA2 positive breast cancers, clear screening guidelines for patients at risk for male for breast cancer have not been established. We report a case of male breast carcinoma in a patient with the BRCA2 mutation detected by screening mammography, and review the literature regarding screening mammography in men.     

Disability After Deployment Injury: Are Women and Men Service Members Different?

Background

Civilian trauma literature suggests sexual dimorphism in outcomes after trauma. Because women represent an increasing demographic among veterans, the question remains if war trauma outcomes, like civilian trauma outcomes, differ between genders.

Questions/purposes

(1) Do women service members develop different conditions resulting in long-term disability compared with men service members after injuries sustained during deployment? (2) Do women service members have more or less severe disability after deployment injury compared with men service members? (3) Are men or women more likely to return to duty after combat injury?

Methods

The Department of Defense Trauma Registry was queried for women injured during deployment from 2001 to 2011. The subjects were then queried in the Physical Evaluation Board database to determine each subject’s return-to-duty status and what disabling conditions and disability percentages were assigned to those who did not return to duty. Frequency of disabling conditions, disability percentages, and return-to-duty rates for 368 women were compared with a previously published cohort of 450 men service members, 378 of whom had orthopaedic injuries.

Results

Women who were unable to return to duty had a higher frequency of arthritic conditions (58% [48 of 83] of women versus 35% [133 of 378] of men, p = 0.002; relative risk [RR], 1.64; 95% confidence interval [CI], 1.307–2.067) and lower frequencies of general chronic pain (1% [one of 83] of women versus 19% [59 of 378] of men, p < 0.001; RR, 0.08; 95% CI, 0.011–0.549) and neurogenic pain disorders (1% [one of 83] of women versus 7% [27 of 378] of men, p = 0.0410; RR, 0.169; 95% CI, 0.023–1.224). Women had more severely rated posttraumatic stress disorder (PTSD) compared with men (38% ± 23% versus 19% ± 17%). Forty-eight percent (64 of 133) of battle-injured women were unable to return to active duty, resulting in a lower return-to-duty rate compared with men (34% [450 of 1333]; p = 0.003).

Conclusions

After deployment-related injury, women have higher rates of arthritis, lower rates of pain disorders, and more severely rated PTSD compared with men. Women are unable to return to duty more often than men injured in combat. These results suggest some difference between men’s and women’s outcomes after deployment injury, important information for military and Veterans Administration providers seeking to minimize postdeployment disability.

Level of Evidence

Level III, prognostic study.     

Strength Performance Assessment in a Simulated Men’s Gymnastics Still Rings Cross

Athletes in sports such as the gymnastics who perform the still rings cross position are disadvantaged due to a lack of objective and convenient measurement methods. The gymnastics “cross ”is a held isometric strength position considered fundamental to all still rings athletes. The purpose of this investigation was to determine if two small force platforms (FPs) placed on supports to simulate a cross position could demonstrate the fidelity necessary to differentiate between athletes who could perform a cross from those who could not. Ten gymnasts (5 USA Gymnastics, Senior National Team, and 5 Age Group Level Gymnasts) agreed to participate. The five Senior National Team athletes were grouped as cross Performers; the Age Group Gymnasts could not successfully perform the cross position and were grouped as cross Non- Performers. The two small FPs were first tested for reliability and validity and were then used to obtain a force-time record of a simulated cross position. The simulated cross test consisted of standing between two small force platforms placed on top of large solid gymnastics spotting blocks. The gymnasts attempted to perform a cross position by placing their hands at the center of the FPs and pressing downward with sufficient force that they could remove the support of their feet from the floor. Force-time curves (100 Hz) were obtained and analyzed for the sum of peak and mean arm ground reaction forces. The summed arm forces, mean and peak, were compared to body weight to determine how close the gymnasts came to achieving forces equal to body weight and thus the ability to perform the cross. The mean and peak summed arm forces were able to statistically differentiate between athletes who could perform the cross from those who could not (p < 0.05). The force-time curves and small FPs showed sufficient fidelity to differentiate between Performer and Non- Performer groups. This experiment showed that small and inexpensive force platforms may serve as useful adjuncts to athlete performance measurement such as the gymnastics still rings cross.

Key points

• Strength-related skills are difficult to assess in some sports and thus require special means.
• Small force platforms have sufficient fidelity to assess the differences between gymnasts who can perform a still rings cross from those who cannot.
• Strength assessment via small force platforms may serve as a means of assessing skill readiness, strength symmetry, and progress in learning a still rings cross.

Key words: Portable force platform, field test