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Second Opinion

Proto readers share their thoughts on CPR, avian flu and testosterone therapy.

FALL 2012
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COMPASSIONATE RELEASE

Having worked almost continuously as a critical-care registered nurse at Massachusetts General Hospital since 1983, I’ve seen my share of horrific resuscitative events such as the ones described in Danielle Ofri’s short story (“Against Nature,” Summer 2012). In response I’d like to quote—as best as memory will serve—a note I read years ago, entered into a patient’s chart by psychiatrist Ned Cassem in his role as consultant on end-of-life issues: “This patient should be compassionately preserved from the assault of CPR.”

Mark Hammerschmidt // Medical Intensive Care Unit, Massachusetts General Hospital, Boston

BIOTERROR’S SHADOW

In your story about fears over publishing the details of new avian flu work (“Playing Chicken,” Summer 2012), I was surprised to see microbiologist Vincent Racaniello ask: “Why would a terrorist want to use something that worked on a ferret without having a clue if it would do the same thing in people?” He is making the same error that so many educated people in the West make. International terrorists don’t think conventionally. Why would anyone want to fly planes into skyscrapers? Why would anyone want to strap a bomb to his chest, walk into a hotel and set it off? Why would anyone want to put a bomb in his undies? None of these makes any sense to us, but to the terrorist mind it all makes perfect sense. To see that such a brilliant mind is stuck in such naïveté is troubling.

My only worry is that our terrorist surveillance capabilities might not be as geared to anomalies in biomedical research attempts as they are to transportation anomalies.

Donald J. Dudley // Department of Obstetrics & Gynecology, University of Texas Health Science Center at San Antonio

THE TESTOSTERONE POLEMIC

In “Gaining Strength,” (Summer 2012), testosterone replacement therapy is depicted in Marvel comic book terms: superhero versus diabolical villain. Therapy proponent Abraham Morgentaler feels “it’s becoming impossible to ignore the notion that low testosterone is a threat to overall health.” The skeptics, on the other hand, argue that the risks of testosterone “triggering prostate cancer cells...outweigh the potential benefits.”

The truth likely resides somewhere between the two strident conclusions. In patients with symptoms and signs of male hypogonadism and unequivocally low serum testosterone levels, there is usually a clinically significant benefit with testosterone therapy. In men who do not have strong evidence of male hypogonadism and are seeking improved vitality or sexual function, testosterone therapy generally confers little benefit.

The symptoms of androgen deficiency are common and often attributable to other causes, thus the diagnosis of male hypogonadism and initiation of therapy often hinges on measurement of low testosterone levels. Hence the glib summary of the marketing campaign: “Is it low T?”

Because millions of men take testosterone, our government and scientists must address the following: standardization of testosterone assays; establishment of a universal normal range for testosterone levels; and funding for studies on the clinical outcomes of long-term therapy in men of different age groups, testosterone levels and health conditions. Until then, it is Iron Man vs. Dr. Doom.

Bradley Anawalt // Chief of Medicine, University of Washington Medical Center, Seattle

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