Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline

OBJECTIVE: Our objective was to develop clinical practice guidelines for the evaluation and treatment of hirsutism in premenopausal women. PARTICIPANTS: The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society, six additional experts, two methodologists, and a medical writer. The Task Force received no corporate funding or remuneration. EVIDENCE: Systematic reviews of available evidence were used to formulate the key treatment and prevention recommendations. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) group criteria to describe both the quality of evidence and the strength of recommendations. We used "recommend" for strong recommendations, and "suggest" for weak recommendations. CONSENSUS PROCESS: Consensus was guided by systematic reviews of evidence and discussions during one group meeting, several conference calls, and e-mail communications. The drafts prepared by the Task Force with the help of a medical writer were reviewed successively by The Endocrine Society's CGS, Clinical Affairs Core Committee (CACC), and Council. The version approved by the CGS and CACC was placed on The Endocrine Society's Web site for comments by members. At each stage of review, the Task Force received written comments and incorporated needed changes. CONCLUSIONS: We suggest testing for elevated androgen levels in women with moderate or severe hirsutism or hirsutism of any degree when it is sudden in onset, rapidly progressive, or associated with other abnormalities such as menstrual dysfunction, obesity, or clitoromegaly. For women with patient-important hirsutism despite cosmetic measures, we suggest either pharmacological therapy or direct hair removal methods. For pharmacological therapy, we suggest oral contraceptives for the majority of women, adding an antiandrogen after 6 months if the response is suboptimal. We recommend against antiandrogen monotherapy unless adequate contraception is used. We suggest against using insulin-lowering drugs. For women who choose hair removal therapy, we suggest laser/photoepilation.     

Exploring Migratory Dynamics on HIV Transmission: The Case of Mexicans in New York City and Puebla,Mexico

Migration and population movement are increasingly viewed as important factors associated with HIV transmission risk. With growing awareness of the potential impact of migration on HIV transmission, several perspectives have emerged that posit differing dynamics of risk. We considered available data on the role of migration on HIV transmission among Mexican migrants in New York City and Puebla, Mexico. Specifically, we examined 3 distinct models of migratory dynamics of HIV transmission—namely, the structural model, the local contextual model, and the interplay model. In doing so, we reframed current public health perspectives on the role of migration on HIV transmission.The epidemiological literature related to Latinos and HIV in the United States highlights geographic disparities in disease burden.1 HIV/AIDS cases among Latinos are clustered geographically, such that Latinos experience increased vulnerability as a function of residence in high-risk physical and geographic areas.2 Recent trends in HIV infection demonstrate that Latino mobility and migratory patterns are potentially associated with increased HIV incidence.3 As a result, several key dynamics to account for the role of migration and HIV transmission have emerged in recent literature. However, to adequately address the current HIV epidemic among Latinos, greater consideration of each of these mechanisms and enhanced attention to the role of geography and migration is warranted.4 Recent findings increasingly draw attention to the role of population mixing and movement, geography, and other physical spaces as important factors for understanding Latino HIV disparities.5 We build upon this work by examining the available empirical literature on HIV and migration in relation to the social structures and contexts in which risk behavior takes place. Specifically, we explored 3 mechanisms for the impact of migration on HIV transmission through the case of Mexican migrants in New York City (NYC) and Puebla.As the epicenter of the HIV/AIDS epidemic in the United States, NYC is one such high-risk geographic area.6 New York City has an incidence rate 3 times the national average and the highest number of AIDS cases relative to any other metropolitan city.6 Latinos in the city are disproportionately affected by the disease and are twice as likely to be diagnosed with HIV/AIDS compared with non-Hispanic Whites.7 Furthermore, although Latinos account for approximately 25% of the population in NYC, they represent 33% of NYC persons living with HIV/AIDS (PLWHA).8,9 Among NYC Latinos, HIV occurs primarily among adults through high-risk sexual behavior and intravenous drug use.10 Specifically, Latino men who have sex with men (MSM) constitute the majority of cases (40%), followed by injection drug users (27%).10 These data suggest that in NYC, Latino MSM and intravenous drug users bear the burden of HIV disease. However, a significant proportion of Latina women in NYC infected with HIV are exposed through high-risk sexual activity (67%) and represents a steady proportion of new HIV diagnoses among women in recent years.11HIV/AIDS is of particular concern among Latinos as they are more likely to experience delays in access to care, which results in adverse health outcomes. For example, Latinos, particularly Mexicans with low levels of acculturation, are less likely to obtain an HIV test.12 Those who are diagnosed often experience rapid progression to AIDS, suggesting that many Latinos are diagnosed late in their infection.6 In 2011, for example, 31% of Latinos diagnosed with HIV in NYC were concurrently diagnosed with AIDS, compared with only 15% of Whites.11 Late diagnosis puts Latinos at greater health risks because they do not receive the benefits of early antiretroviral treatment.13 In addition to late diagnosis and delayed treatment, obstacles in access to HIV treatment for Latinos include lack of a designated routine health care provider and adequate health insurance.14Increasingly, the Latino population in NYC has undergone important demographic changes.15 Specifically, migratory changes have shifted the composition of the Latino population in NYC, introducing new Latino subgroups to a geographic area of heightened HIV risk. Traditionally, the Latino population in NYC has been classified as largely stemming from the Caribbean—specifically, Puerto Rico and the Dominican Republic. However, Mexicans, whose US migration patterns have traditionally been associated with the areas of the Southwest, are increasingly moving to NYC, a nontraditional receiving community.For example, the Mexican population in NYC in 2010 was more than 5 times what it was in 1990.16 In 1990, an estimated 56 700 Mexicans were living in NYC; by 2000, this number grew to 180 000, and later to 325 000 in 2010.16 Foreign-born males with less than a high-school education represent the bulk of the Mexican population growth and a significant portion of this population attains employment in NYC.15 By 2024, it is predicted that Mexicans will be the most populous Latino ethnic subgroup in the largest city of the United States.17 One notable feature of NYC’s Mexican community is that nearly half (45%) originates from the state of Puebla in east-central Mexico, although other sources suggest far higher proportions (more than 70%).18 Data from the American Community Survey demonstrate that Mexican-born persons are geographically clustered in specific target communities, predominantly the Bronx and Queens (Figure 1).19Open in a separate windowFIGURE 1—Foreign-born from Mexico by Public Use Microdata Areas in New York City: 2006–2008.Note. PUMA = Public Use Microdata Area.Source. US Census Bureau.20     

Glutamate Excitotoxicity Activates the MAPK/ERK Signaling Pathway and Induces the Survival of Rat Hippocampal Neurons In Vivo

Current knowledge concerning the molecular mechanisms of the cellular response to excitotoxic insults in neurodegenerative diseases is insufficient. Although glutamate (Glu) has been widely studied as the main excitatory neurotransmitter and principal excitotoxic agent, the neuroprotective response enacted by neurons is not yet completely understood. Some of the molecular participants have been revealed, but the signaling pathways involved in this protective response are just beginning to be identified. Here, we demonstrate in vivo that, in response to the cell damage and death induced by Glu excitotoxicity, neurons orchestrate a survival response through the extracellular signal-regulated kinase (ERK) signaling pathway by increasing ERK expression in the rat hippocampal (CA1) region, allowing increased neuronal survival. In addition, this protective response is specifically reversed by U0126, an ERK inhibitor, which promotes cell death only when it is administered together with Glu. Our findings demonstrate that the ERK signaling pathway has a neuroprotective role in the response to Glu-induced excitotoxicity in hippocampal neurons. Therefore, the ERK signaling pathway may be activated as a cellular response to excitotoxic injury to prevent damage and neural loss, representing a novel therapeutic target in the treatment of neurodegenerative diseases.     

Factors associated with potentially inappropriate medications use by the elderly according to Beers criteria 2003 and 2012

Background Potentially inappropriate medications (PIMs) should be avoided by the elderly because they possess a significant high risk for this population when a safer alternative is available. Therefore, the identification of prevalence and factors associated with PIMs should be considered as they provide valuable information that can be used to develop strategies to ensure patients’ safety. Objective To identify the prevalence and the clinical and socioeconomic–demographic factors that may be associated with PIMs use in the elderly, according to Beers criteria 2003 and its updated version 2012. And, as a secondary objective, a comparison between both criteria was performed. Setting Pharmacy of the Basic Health District Unit of the western district of Ribeirão Preto. Methods This cross-sectional observational study was conducted with the elderly, assisted by the Brazilian public health system. Data from patients were collected through a structured interview form. Beers criteria 2003 and 2012 were used to classify PIMs. The association between PIMs used and independent variables were analyzed by odds ratios. The differences between PIMs use according to Beers criteria 2003 and 2012 were analyzed by McNemar’s test and the agreement by kappa coefficient. Main outcome measure Prevalence and factors associated with PIMs use in Brazilian elderly outpatients. Results One thousand elderly patients were interviewed. High prevalence of PIMs use was observed, 48.0 and 59.2 % according to Beers criteria 2003 and 2012, respectively. The factors associated with PIMs use, common for both criteria, are female gender, self-medication, use of over the counter drugs, complaints related to adverse drug event, psychotropic medication, polypharmacy and some categories of drugs. PIMs use is different between Beers criteria 2003 and 2012 (McNemar’s test, p < 0.01), although a substantial agreement between these classifications was observed (kappa coefficient 0.635, 95% confidence intervals (0.588, 0.681). Conclusions Our study showed a high prevalence of PIMs use, which is associated with various clinical and social–demographic factors. When comparing both criteria through McNemar’s test, PIMs use was considered different. The differences may have occurred because medications with high prevalence of use in Brazil were included in Beers criteria 2012 .