Erectile dysfunction is thought to affect some 150 million men worldwide, but many men with ED symptoms do not seek treatment. Existing surveys suggest that men with severe ED and who report support from their partners are more likely to receive treatment than were others. Less is known, however, concerning the influence of sociomedical factors such as income and body composition on receipt of treatment.
To determine the importance of socioeconomic status, comorbidities and body composition on receipt of treatment for ED symptoms.
We used data on 638 men enrolled in the Boston Area Community Health (BACH) survey reporting ED symptoms and/or treatment for ED as evidenced by phosphodiesterase type 5 inhibitor (PDE5i) use. Logistic regression was employed to assess the relative strength of association between receipt of treatment and socioeconomic factors, BMI, and medical factors. A replication of these results was then provided via a parallel model using the 2004 follow-up of the Men’s Attitudes to Life Events and Sexuality (MALES).
Main outcome measure
In BACH, ED was deemed present if a subject scored 16 points or fewer on the five-item International Index of Erectile Function (IIEF-5) or reported PDE5i use. In MALES, presence of ED was indicated by use of a validated single question querying ED severity.
Controlling for age, body composition and other factors, increased household income, availability of a sexual partner and provider diagnosis of high blood pressure were positively associated with treatment seeking via the use of PDE5i therapy in BACH. Results on data available in MALES produced similar results for household income and partner availability.
These data provide evidence that financial disadvantage may present a barrier to treatment of ED, an increasingly important sentinel marker of the cardiovascular and overall health among aging men.
Erectile dysfunction (ED) and cardiovascular disease (CVD) share pathophysiological mechanisms and often co-occur. Yet it is not known whether ED provides an early warning for increased CVD or other causes of mortality.
We sought to examine the association of ED with all-cause and cause-specific mortality.
Prospective, population-based study of 1,709 men (of 3,258 eligible) aged 40–70 years. ED was measured by self-report. Subjects were followed for a mean of 15 years. Hazard ratios (HR) were calculated using the Cox proportional hazards regression model.
Main outcome measures
Mortality due to all causes, CVD, malignant neoplasms, and other causes.
Of 1,709 men, 1,284 survived to the end of 2004 and had complete ED and age data. Of 403 men who died, 371 had complete data. After adjustment for age, body mass index, alcohol consumption, physical activity, cigarette smoking, self-assessed health, and self-reported heart disease, hypertension, and diabetes, ED was associated with HRs of 1.26 [95% confidence interval (CI), 1.01–1.57] for all-cause mortality and 1.43 (95% CI, 1.00–2.05) for CVD mortality. The HR for CVD mortality associated with ED is of comparable magnitude to HRs of some conventional CVD risk factors.
These findings demonstrate that ED is significantly associated with increased all-cause mortality, primarily through its association with CVD mortality.
Aging; erectile dysfunction; cardiovascular disease; longitudinal studies; men; mortality
The association between total testosterone and metabolic syndrome has prompted speculation that low testosterone contributes to the pathophysiology of metabolic syndrome in men. We determined whether testosterone or sex hormone–binding globulin (SHBG) is independently associated with the risk of metabolic syndrome.
RESEARCH DESIGN AND METHODS
Cross-sectional relationships of hormone levels with metabolic syndrome were assessed in a sample of men in generation 2 of the Framingham Heart Study (FHS) who did not receive testosterone or androgen-deprivation therapy (n = 1,625) and confirmed in a validation sample of men in FHS generation 3 (n = 1,912). Hormone levels in generation 2 examination 7 were related prospectively to incident metabolic syndrome 6.6 years later at examination 8. Testosterone was measured using liquid chromatography–tandem mass spectrometry, SHBG was measured by immunofluorometric assay, and free testosterone was calculated. Metabolic syndrome was defined using the National Cholesterol Education Program Adult Treatment Panel III criteria.
Cross-sectionally, testosterone and SHBG were more strongly associated with metabolic syndrome than free testosterone in the training sample. SHBG, but not testosterone or free testosterone, was significantly associated with metabolic syndrome after adjusting for age, smoking, BMI, and insulin sensitivity (homeostasis model assessment of insulin resistance [HOMA-IR]). These findings were confirmed in a validation sample. Longitudinally, SHBG at examination 7, but not testosterone or free testosterone, was associated with incident metabolic syndrome at examination 8 after adjusting for age, smoking, BMI, and HOMA-IR. Multivariable analyses suggested that age, BMI, and insulin sensitivity independently affect SHBG and testosterone levels and the risk of metabolic syndrome and its components.
SHBG, but not testosterone, is independently associated with the risk of metabolic syndrome. These data do not reveal an independent prospective relationship between testosterone and metabolic syndrome in men.
Racial/ethnic variation in fracture risk is well-documented, but the mechanisms by which such heterogeneity arises are poorly understood. We analyzed data from black, Hispanic and white men enrolled in the Boston Area Community Health/Bone (BACH/Bone) Survey to determine the contributions of risk factors to racial/ethnic differences in bone mineral content (BMC) and density (BMD).
In a population-based study, BMC, BMD and body composition were ascertained by DXA. Socioeconomic status, health history and dietary intake were obtained via interview. Hormones and markers of bone turnover were obtained from non-fasting blood samples. Multivariate analyses measured percentage reductions in estimated racial/ethnic differences in BMC/BMD accompanying the successive removal of covariates from linear regression models.
Black men demonstrated greater BMC than their Hispanic and white counterparts. At the femoral neck, adjustment for covariables was sufficient to reduce these differences by 46% and 35%, respectively. While absolute differences in BMC were smaller at the distal radius than femoral neck, the proportionate reductions in racial/ethnic differences after covariable adjustment were comparable or greater. Multivariate models provided evidence that lean and fat mass, serum 25(OH)D, osteocalcin, estradiol, and aspects of socioeconomic status influence the magnitude of racial/ethnic differences in BMC, with lean and fat mass providing the strongest effects. Results for BMD were similar but typically of lesser magnitude and statistical significance.
These cross-sectional analyses demonstrate that much of the racial/ethnic heterogeneity in measures of bone mass and density can be accounted for through variation in body composition, diet, and sociodemographic factors.
bone densitometry; epidemiology; men; osteoporosis; population study; race/ethnicity
Testosterone in Older Men with Mobility Limitations Trial determined the effects of testosterone on muscle performance and physical function in older men with mobility limitation. Trial’s Data and Safety Monitoring Board recommended enrollment cessation due to increased frequency of adverse events in testosterone arm. The changes in muscle performance and physical function were evaluated in relation to participant’s perception of change.
Men aged 65 years and older, with mobility limitation, total testosterone 100–350 ng/dL, or free testosterone less than 50 pg/mL, were randomized to placebo or 10 g testosterone gel daily for 6 months. Primary outcome was leg-press strength. Secondary outcomes included chest-press strength, stair-climb, 40-m walk, muscle mass, physical activity, self-reported function, and fatigue. Proportions of participants exceeding minimally important difference in study arms were compared.
Of 209 randomized participants, 165 had follow-up efficacy measures. Mean (SD) age was 74 (5.4) years and short physical performance battery score 7.7 (1.4). Testosterone arm exhibited greater improvements in leg-press strength, chest-press strength and power, and loaded stair-climb than placebo. Compared with placebo, significantly greater proportion of men receiving testosterone improved their leg-press and chest-press strengths (43% vs 18%, p = .01) and stair-climbing power (28% vs 10%, p = .03) more than minimally important difference. Increases in leg-press strength and stair-climbing power were associated with changes in testosterone levels and muscle mass. Physical activity, walking speed, self-reported function, and fatigue did not change.
Testosterone administration in older men with mobility limitation was associated with patient-important improvements in muscle strength and stair-climbing power. Improvements in muscle strength and only some physical function measures should be weighed against the risk of adverse events in this population.
Testosterone; Minimally important difference; Mobility limitation; Older men; Function promoting therapies
Testosterone supplementation has been shown to increase muscle mass and strength in healthy older men. The safety and efficacy of testosterone treatment in older men who have limitations in mobility have not been studied.
Community-dwelling men, 65 years of age or older, with limitations in mobility and a total serum testosterone level of 100 to 350 ng per deciliter (3.5 to 12.1 nmol per liter) or a free serum testosterone level of less than 50 pg per milliliter (173 pmol per liter) were randomly assigned to receive placebo gel or testosterone gel, to be applied daily for 6 months. Adverse events were categorized with the use of the Medical Dictionary for Regulatory Activities classification. The data and safety monitoring board recommended that the trial be discontinued early because there was a significantly higher rate of adverse cardiovascular events in the testosterone group than in the placebo group.
A total of 209 men (mean age, 74 years) were enrolled at the time the trial was terminated. At baseline, there was a high prevalence of hypertension, diabetes, hyperlipidemia, and obesity among the participants. During the course of the study, the testosterone group had higher rates of cardiac, respiratory, and dermatologic events than did the placebo group. A total of 23 subjects in the testosterone group, as compared with 5 in the placebo group, had cardiovascular-related adverse events. The relative risk of a cardiovascular-related adverse event remained constant throughout the 6-month treatment period. As compared with the placebo group, the testosterone group had significantly greater improvements in leg-press and chest-press strength and in stair climbing while carrying a load.
In this population of older men with limitations in mobility and a high prevalence of chronic disease, the application of a testosterone gel was associated with an increased risk of cardiovascular adverse events. The small size of the trial and the unique population prevent broader inferences from being made about the safety of testosterone therapy.
To determine the effects of creation of a systemic to pulmonary venous atrial level communication (fenestration) at the time of the Fontan procedure on late outcomes.
Fenestrations are frequently performed during Fontan procedures but late consequences are not well described.
Patient characteristics were compared between those with and without surgical fenestration among 536 subjects (mean 11.9 years) enrolled in the Pediatric Heart Network Fontan Cross-sectional Study. The status of the fenestration and the association of a currently patent fenestration with health status and measures of ventricular performance were investigated.
Fenestration was performed in 361 patients (67%) and frequency differed by year and center (p<0.001 for each). After adjustment for center, age at Fontan, year of Fontan and prior superior cavopulmonary surgery, the fenestrated group had shorter length of Fontan hospital stay. At time of cross-sectional testing 8±3 years after Fontan, the fenestration remained open in 19% of subjects. Among those with confirmed fenestration closure, 59% were by catheter intervention, 1% by surgical intervention, and 40% had apparent spontaneous closure. Compared to those without evidence of a fenestration, subjects with a current fenestration were taking more medications (p=0.02) and had lower resting oxygen saturation (median 89 vs. 95%, p<.001). Functional health status, exercise performance, echocardiographic variables, prevalence of post Fontan stroke or thrombosis, and growth did not differ by current fenestration status.
Surgical fenestration is associated with well demonstrated early postoperative benefits. This cross-sectional study found few associations between a persistent fenestration and deleterious later outcomes.
Congenital Heart Disease; Cardiac surgery; Fontan procedure
Prostate cancer (PCa) is the most common visceral malignancy in men with androgen deprivation therapy (ADT) the preferred therapy to suppress testosterone production and hence tumor growth. Despite its effectiveness in lowering testosterone, ADT is associated with side effects including loss of muscle mass, diminished muscle strength, decrements in physical performance, earlier fatigue and declining quality of life. This review reports a survey of the literature with a focus on changes in muscle strength, physical function and body composition, due to short-term and long-term ADT. Studies in these areas are sparse, especially well-controlled, prospective randomized trials. Cross-sectional and longitudinal data (up to 2 years) for men with PCa treated with ADT as well as patients with PCa not receiving ADT and age-matched healthy men are presented when available. Based on limited longitudinal data, the adverse effects of ADT on muscle function, physical performance and body composition occur shortly after the onset of ADT and tend to persist and worsen over time. Exercise training is a safe and effective intervention for mitigating these changes and initial guidelines for exercise program design for men with PCa have been published by the American College of Sports Medicine. Disparities in study duration, types of studies and other patient-specific variables such as time since diagnosis, cancer stage and comorbidities may all affect an understanding of the influence of ADT on health, physical performance and mortality.
androgen deprivation therapy; androgen suppression; exercise prescription; exercise training; functional assessment; lean body mass; older men; prostate cancer
The profound hypogonadism that occurs with androgen-deprivation therapy (ADT) for prostate cancer (PCa) results in complications such as diabetes and metabolic syndrome that predispose to cardiovascular disease. Since phytoestrogens have been associated with an improvement in metabolic parameters, we evaluated their role in men undergoing ADT.
To evaluate the effects of high-dose isoflavones on metabolic and inflammatory parameters in men undergoing ADT.
This was a randomized, double-blind, placebo-controlled, 12-week pilot study. Participants were randomly assigned to receive 20 g of soy protein containing 160 mg of total isoflavones vs taste-matched placebo (20 g whole milk protein). The study was conducted at a tertiary care center in the United States.
Thirty-three men (isoflavones=17, placebo=16) undergoing ADT for PCa completed this pilot study. Mean age in the two groups was 69 years and majority of men were Caucasians. Mean duration of ADT in both groups was approximately 2 years (P=0.70). The two groups were well-matched at baseline. After 12-weeks of intervention, there was no significant difference in either metabolic or inflammatory parameters between the two groups.
High-dose isoflavones over a course of 12-weeks do not improve metabolic or inflammatory parameters in androgen deprived men.
The purpose of this analysis was to assess preoperative risk factors prior to the first-stage Norwood surgery in infants with hypoplastic left heart syndrome and related single ventricle lesions, and to evaluate practice patterns in prenatal diagnosis as well as the role of prenatal diagnosis in outcome.
Data from all live births with morphologic single right ventricle and systemic outflow obstruction screened for the Pediatric Heart Network Single Ventricle Reconstruction Trial were used to investigate prenatal diagnosis and preoperative risk factors. Demographics, gestational age, prenatal diagnosis status, presence of major extracardiac congenital abnormalities and preoperative mortality rates were recorded.
Of 906 infants, 677 (75%) had prenatal diagnosis, 15% were preterm (<37 weeks), and 16% were low birth weight (<2500 g). Rates of prenatal diagnosis varied by study site (59%-85%, p<0.0001). Major extracardiac congenital abnormalities were less prevalent in those born after prenatal diagnosis (6% vs. 10%, p=0.03). There were 26 (3%) deaths prior to Norwood palliation; preoperative mortality did not differ by prenatal diagnosis status (p=0.49). In multiple logistic regression models, preterm birth (p=0.02), major extracardiac congenital abnormalities (p<0.0001), and obstructed pulmonary venous return (p=0.02) were independently associated with preoperative mortality.
Prenatal diagnosis occurred in 75%. Preoperative death was independently associated with preterm birth, obstructed pulmonary venous return and major extracardiac congenital abnormalities. Adjusted for gestational age and the presence of obstructed pulmonary venous return, the estimated odds of preoperative mortality were 10 times greater for subjects with a major extracardiac congenital abnormality.
The effects of the nondominant or secondary ventricle on the Fontan circulation are not known. The present study used cardiac magnetic resonance imaging to investigate the relations between secondary ventricular size and global cardiac performance. The Fontan cross-sectional study collected data from 7 centers participating in the Pediatric Heart Network. Subjects with complete cardiac magnetic resonance imaging data and an identifiable secondary ventricle were included in the analysis. Relationships between body surface area–adjusted parameters of the secondary ventricle (mass, end-diastolic volume, mass/volume ratio, and stroke volume) and the following measures were assessed. These measures included the percentage of predicted peak oxygen consumption and oxygen consumption at the ventilatory anaerobic threshold, ejection fraction of the main ventricular chamber, echocardiographic diastolic function grade, serum B-type natriuretic peptide, primary ventricular end-diastolic pressure, and parent-reported physical functioning summary score on the Child Health Questionnaire. Of the 546 enrolled subjects, 123 (age 12.1 ± 3.3 years, 56% male) had undergone cardiac magnetic resonance imaging, and 38 had achieved maximal aerobic capacity. A larger secondary ventricular end-diastolic volume, lower mass/volume ratio, and greater secondary/total ventricular stroke volume ratio were associated with a greater exercise capacity. No significant relationships were found between the measures of the secondary ventricle and the other outcomes. In conclusion, in children after the Fontan operation, a larger and less hypertrophied secondary ventricle with a greater contribution to stroke volume was associated with a better exercise capacity.
A picture may be worth a thousand words but in medical research, caution Stuart Pocock, Thomas Travison, and Lisa Wruck, it is important to understand exactly what you are looking at
Studies and reports suggest that both hyperlipidemia and its pharmacologic treatment may lead to an increased risk of erectile dysfunction (ED).
Our objectives were to examine the association between 1) treated hyperlipidemia and ED; 2) untreated hyperlipidemia and ED.
Data from 1,899 men aged 30–79 were used from the Boston Area Community Health Survey of community-dwelling residents of Boston, MA, collected during 2002–2005 using an in-person interview, self-administered questionnaires, and a venous blood draw.
Main Outcome Measures
ED was measured using the Short Form International Index of Erectile Function. A case of treated hyperlipidemia was defined by use of anti-lipemics in the past month, while untreated hyperlipidemia was serum total cholesterol ≥240 milligrams per deciliter with no anti-lipemic use. We estimated associations using odds ratios (ORs) and 95% confidence intervals (CIs) from multivariate logistic regression.
Men with treated hyperlipidemia were older, had more comorbidities and used more medications compared to men with untreated hyperlipidemia or no hyperlipidemia. In multivariate models stratified by age and the presence of diabetes and/or cardiovascular disease (CVD), we saw no association between hyperlipidemia drug treatment and ED, except among younger men (<55) who had diabetes and/or CVD, where a strong association with an imprecise confidence interval was observed (OR=10.39, 95% CI: 3.25, 33.20). There was no significant positive association between untreated hyperlipidemia and ED in any multivariate model.
Lipid-lowering medications may be associated with ED among some men. The well-established benefits of lipid-lowering therapy should always be weighed against potential adverse effects.
To determine whether erectile dysfunction (ED) predicts cardiovascular disease (CVD) beyond traditional risk factors.
ED and CVD share pathophysiological mechanisms and often co-occur. It is unknown whether ED improves the prediction of CVD beyond traditional risk factors.
This was a prospective, population-based study of 1,709 men (of 3,258 eligible) aged 40–70 years. ED was measured by self-report. Subjects were followed for CVD for an average follow-up of 11.7 years. The association between ED and CVD was examined using the Cox proportional hazards regression model. The discriminatory capability of ED was examined using c statistics. The reclassification of CVD risk associated with ED was assessed using a method that quantifies net reclassification improvement.
1,057 men with complete risk factor data who were free of CVD and diabetes at baseline were included. During follow-up, 261 new cases of CVD occurred. ED was associated with CVD incidence controlling for age (Hazard Ratio (HR): 1.42 (95% Confidence Interval (CI)): 1.05, 1.90), age and traditional CVD risk factors (HR: 1.41, 95% CI: 1.05, 1.90), as well as age and Framingham risk score (HR: 1.40, 95% CI: 1.04–1.88). Despite these significant findings, ED did not significantly improve the prediction of CVD incidence beyond traditional risk factors.
Independent of established CVD risk factors, ED is significantly associated with increased CVD incidence. Nonetheless, ED does not improve the prediction of who will and will not develop CVD beyond that offered by traditional risk factors.
Aging; erectile dysfunction; cardiovascular disease; longitudinal studies; men
Osteoporosis in men has gained recognition as a public health problem, generating an interest in the search for risk factors. Isolation of individual risk factors could allocate disproportionate attention to relationships that may be of limited consequence.
The Boston Area Community Health/Bone (BACH/Bone) Survey is a population-based study of randomly-selected community-dwelling men (age 30-79 y). Bone mineral density (BMD) and lean mass were measured by dual x-ray absorptiometry. Socioeconomic status, health history, and lifestyle factors were obtained via interview. Hormone levels and markers of bone turnover were obtained from non-fasting blood samples. Multivariate analyses measured relative contributions of covariates to femoral neck (hip), 1/3 distal radius (wrist), and lumbar spine BMD.
Factors positively associated with BMD in multivariate models at the three sites were black race and appendicular lean mass. Asthma was consistently negatively associated. Various other risk factors also contributed significantly to each of the individual sites. R2 values for the hip, wrist, and spine were 41%, 30%, and 24% respectively. Lean mass accounted for the most explained variance at all three sites.
These data emphasize the limitation of focusing on individual risk factors and highlight the importance of potentially modifiable lean mass in predicting BMD.
aging; body composition; bone mineral density; men; population studies
To examine the association between aging and physical function in men by testing a theoretically-based model of aging, hormones, body composition, strength, and physical function with data obtained from men enrolled in the Boston Area Community Health/Bone (BACH/Bone) Survey.
Cross-sectional, observational survey.
810 Black, Hispanic, and White Boston randomly-selected men ages of 30–79 y.
Testosterone, estradiol, sex hormone-binding globulin, lean and fat mass, grip strength, and summated index of physical function (derived from walk and chair stand tests).
Measures of grip strength and physical function declined strongly associated with age. For instance, 10 y of aging was associated with a 0.49-point difference (scale: 0–7) in physical function. Age differences in total testosterone and estradiol concentrations were smaller than age differences in their free fractions. Weak or non-significant age-adjusted correlations were observed between hormones and measures of physical function. Path analysis, however, revealed a positive association between testosterone and appendicular lean mass, and a strong negative association between testosterone and total fat mass. Lean and fat mass, in turn, were strongly associated with grip strength and physical function, indicating the possibility of testosterone influencing physical function via indirect associations with body composition.
The age-related decline in serum testosterone concentration in men has a relatively weak association with physical strength and functional outcomes via its associations with lean and fat mass.
aging; androgens; body composition; estrogens; men; physical function; population studies
Disparities within ethnic groups are generally ignored, but in evolving populations they may have implications for public health. We examined ethnic variation in serum 25-hydroxyvitamin D [25(OH)D] and bone mineral density (BMD) among Hispanic American men.
358 Hispanic males age 30–79 y were studied. Logistic regression models assessed variation in odds of vitamin D deficiency (<20 ng/mL) and low BMD (T-score<−1) by ethnicity, with and without adjustment for risk factors (age, smoking, occupation, physical activity, body mass index, and sunlight exposure).
Vitamin D deficiency was most common among Puerto Rican (26%), compared with Dominican (21%), Central American (11%), and South American (9%) men. Percentages with low BMD were: South American (44%), Puerto Rican (34%), Dominican (29%), and Central American (23%). Adjustment for age and risk factors failed to account for Hispanic subgroup differences in vitamin D deficiency and low BMD. Population estimates indicate a substantial burden of low BMD and vitamin D deficiency among Hispanic men.
Our findings underscore the importance of examining the skeletal health of Hispanic subgroups, and suggest that a considerable number of Hispanic men may be at elevated risk of fracture and vitamin D deficiency.
bone densitometry; epidemiology; Hispanic; men; population study; vitamin D
In addition to being prevalent and bothersome, urologic and sexual symptoms may be related to chronic medical illnesses. We investigate the relationship between ten urologic and sexual symptoms and four major illnesses (type II diabetes, cardiac disease, hypertension, and depression).
We analyze data from the Boston Area Community Health (BACH) Survey, a community-based epidemiologic study of urologic symptoms and risk factors. BACH used a two-stage stratified cluster sampling design to recruit 5,506 adults aged 30–79 (2,301 men, 3,205 women; 1,770 Black, 1,877 Hispanic, and 1,859 White respondents).
In bivariate analyses, most urologic and sexual symptoms are associated with type II diabetes, cardiac disease, hypertension, and depression. However, in multivariate models adjusting for all four illnesses, gender, race/ethnicity, age, alcohol intake, smoking, physical activity, and body mass index there were fewer significant associations. We found that all urologic symptoms were significantly related to at least one illness, with depression increasing the odds of all urologic and sexual symptoms studied.
Urinary tract specialists may need to give greater weight to consideration of factors outside the urinary tract that may be contributing to urologic symptoms. It remains unknown whether treatment of medical and psychological illnesses can result in meaningful improvement in urologic symptoms, or conversely, whether urinary tract symptoms can provide valuable insight into an individual’s overall health status.
epidemiology; diabetes; hypertension; cardiac disease; depression; lower urinary tract symptoms; painful bladder syndrome; urinary incontinence; prostatitis; overactive bladder; frequency; urgency; nocturia; erectile dysfunction; female sexual dysfunction
Most clinical trial publications include figures, but there is little guidance on what results should be displayed as figures and how.
To evaluate the current use of figures in Trial reports, and to make constructive suggestions for future practice.
We surveyed all 77 reports of randomised controlled trials in five general medical journals during November 2006 to January 2007. The numbers and types of figures were determined, and then each Figure was assessed for its style, content, clarity and suitability. As a consequence, guidelines are developed for presenting figures, both in general and for each specific common type of Figure.
Most trial reports contained one to three figures, mean 2.3 per article. The four main types were flow diagram, Kaplan Meier plot, Forest plot (for subgroup analyses) and repeated measures over time: these accounted for 92% of all figures published. For each type of figure there is a considerable diversity of practice in both style and content which we illustrate with selected examples of both good and bad practice. Some pointers on what to do, and what to avoid, are derived from our critical evaluation of these articles' use of figures.
There is considerable scope for authors to improve their use of figures in clinical trial reports, as regards which figures to choose, their style of presentation and labelling, and their specific content. Particular improvements are needed for the four main types of figures commonly used.