Morning Report: Benign Positional Vertigo Guidelines; Insect Repellents; Testosterone Gel Speeds Atherosclerosis

Arefa Cassoobhoy, MD, MPH


March 10, 2017

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Hello. I'm Dr Arefa Cassoobhoy, a practicing internist and a medical editor for Medscape and WebMD. Welcome to our weekly brief on recent medical news and findings.

New Benign Paroxysmal Positional Vertigo Guidelines

We have updated guidelines that should improve quality of life for patients with benign paroxysmal positional vertigo (BPPV).

The use of canalith repositioning procedures is now strongly recommended as initial therapy for patients with BPPV. This has proven effective for symptom control and can prevent the need for vestibular suppressant medications. And, in a change to an approach used in the past, the guidelines now recommend against routine application of postprocedure activity restrictions. This allows a faster return to normal lifestyle, less interruption of sleep and work, reduced musculoskeletal discomfort, and lower cost.

Also, patient education is emphasized because BPPV can be so frustrating. The clinical practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery also includes guidance for clinicians to keep patients informed about their diagnosis, symptoms, and treatment expectations, as well as safety risks and any needed follow-up care.

Which Insect Repellents Really Work?

Next, a new study confirms that not all insect repellents are equally effective at keeping mosquitoes away.

In the wake of concerns over the Zika virus, there has been widespread interest in mosquito control, particularly for the Aedes aegypti mosquito, which spreads Zika, yellow fever, dengue, and chikungunya. Researchers used human volunteers to test the efficacy of 11 spray-on repellents as well as five wearable devices—and even one citronella candle—to find out what works and what doesn't.

Sprays were by far the most effective deterrent, mainly those containing DEET or oil of lemon eucalyptus, which contains the active ingredient PMD. Four of the five wearable devices tested did nothing to repel mosquitoes. The citronella candle, placed on the ground next to the volunteer, likewise didn't work.

For effective mosquito control, remind your patients to read labels carefully to ensure a high enough concentration of DEET or oil of lemon eucalyptus. The Centers for Disease Control and Prevention recommends at least 20% DEET.

Testosterone Gel Speeds Atherosclerosis

And finally, the use of topical testosterone could speed up atherosclerosis in older men. This was the major finding of an National Institutes of Health trial[1] that examined clinical outcomes in older men with age-related low testosterone levels.

The randomized trial involved 138 men with a mean age of 71 years who had subjective and objective evidence of sexual dysfunction, physical dysfunction, and/or reduced vitality. Many, like expected, had cardiovascular risk factors. Half of the men had severe atherosclerosis before starting testosterone treatment.

The plan was to achieve testosterone levels of men 40 years younger. The trial's hypothesis was that testosterone therapy would slow the progression of noncalcified coronary artery plaque volume.

But they found that men who used testosterone gel for a year had a 20% higher buildup of noncalcified plaque in their coronary arteries compared with those who used a placebo gel. The trial wasn't long enough to determine whether testosterone would also lead to an increase in cardiovascular events, but this information leads us to be cautious in prescribing testosterone to men with cardiovascular risk factors.

For Medscape and WebMD, I'm Dr Arefa Cassoobhoy.

Follow Dr Cassoobhoy on Twitter at @ArefaMD


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