Incidentalomas. A disease of modern technology.

The optimal strategy for hormonal screening of a patient with any incidentally discovered adrenal or pituitary mass is unknown. Our review of the endocrinologic literature supports the view that such patients are at slightly increased risk for morbidity and mortality. There is a benefit of early diagnosis for at least for some of the disorders, suggesting the importance of case finding. The data in Tables 1 and 4 illustrate that clinically diagnosed hormone-secreting adrenal and pituitary tumors are far less common than incidentalomas. From a clinical perspective, our ability to determine accurately those at increased risk among the vast majority who are not at increased risk is poor. Given the limitations of diagnostic tests, effective hormonal screening requires a sufficiently high pretest probability to limit the number of false-positive results. This condition is met to varying degrees in the patient with an adrenal mass or small incidentally discovered pituitary mass but no signs or symptoms of hormone excess. Even the more common lesions such as pheochromocytoma and prolactinoma are relatively rare. Subjecting patients to unnecessary testing and treatment carries its own set of risks. Initial costs aside, testing may result in further expense and harm as false-positive results are pursued, producing the cascade effect described by Mold and Stein as a "chain of events (which) tends to proceed with increasing momentum, so that the further it progresses the more difficult it is to stop." The extensive evaluations performed in some patients with incidentally discovered masses may reflect the unwillingness of many physicians to accept uncertainty, even in the case of extremely unlikely diagnoses. This unwillingness may be driven, in part, by fear of potential malpractice liability, the failure to appreciate the influence of prevalence data on the interpretation of diagnostic testing, or other factors. Indeed, the major justification for further evaluation of these patients is not so much to avoid morbidity and mortality for rate patients who truly are at increased risk but rather to reassure those in whom further testing is negative (and to reassure ourselves). Physicians must take care not to create inappropriate anxiety in patients by overemphasizing the importance of an incidental finding unless it is associated with a realistic clinical risk. Our recommendations utilize currently available information to minimize the untoward effects of the cascade. As evidence accumulates, recommendations may need to be revised. The benefit of diagnosis of one of these adrenal or pituitary disorders must be considered in the context of the patient's overall condition. Studies are needed to analyze the utility in clinical practice of hormonal screening for these common radiologic findings. We need to use these studies to identify the critical gaps in our knowledge and to adopt the epidemiologic methods of evaluation of evidence that have been applied to preventive measures. We must be careful to recognize lead-time bias in which survival can seem to be lengthened when screening simply advances the time of diagnosis, lengthening the period of time between diagnosis and death without any true prolongation of life. Length bias refers to the tendency of screening to detect a disproportionate number of cases of slowly progressive disease and to miss aggressive cases that, by virtue of rapid progression, are present in the population only briefly. Endocrinologists must avoid the pitfalls of overestimation of disease prevalence and of the benefits of therapy resulting from advances in diagnostic imaging. Clinical judgment based on the best available evidence should be complemented and not replaced by laboratory data.

Age-associated changes in quantitative ultrasonometry (QUS) of the os calcis in Lebanese women-assessment of a Lebanese reference population.

OBJECTIVE: This study was aimed to assess age changes in quantitative ultrasonometry (QUS) in a large sample of Lebanese women to determine a Lebanese reference population. DESIGN: Cross-sectional study. SUBJECTS AND METHODS: Broadband ultrasound attenuation (BUA) and speed of sound (SOS) and the stiffness index (SI) of the os calcaneus was measured in 4,320 women with a mean age of 52.5 years (age range 20 to 79 years) using three identical Achilles Express (GE/Lunar) and one Achilles Plus (GE/Lunar) ultrasonometry devices. Women were randomly selected and asked to participate in a nationwide screening program using the media, conferences, telephone calls etc. Measurements were performed at Red Cross centers located all over the country. No inclusion or exclusion criteria were used. RESULTS: There was an overall decline of 19.2% for BUA, 3.1% for SOS and 30.3% for SI between late adolescence and old age. In premenopausal women, BUA decreased only slightly by 3%, while postmenopausal women showed a significant decline of 16.2%. In contrast, SOS continuously decreased from the age of 42; there was a decline of 0.8% from adolescence to the menopause; postmenopausal women showed a larger decline of 2.4%. The SI of premenopausal women decreased by 6%, while postmenopausal women showed a significantly larger decline of 24.3%. SI value for the female Lebanese young adult reference is 8% lower than that of the American and European women (92 SI units compared to 100). At the age of 42, SI value for the Lebanese women is 10.4% lower than the American women and 7.5% lower than the European women (86 SI units compared to 96 and 93, respectively). At the age of 75, SI values for the Lebanese women is 4.4% lower than the American women and the European women (65 SI units compared to 68). The decline in stiffness index for the Lebanese women between age 20 and 75 years is about 30.3% compared to 32% for the American or European reference curves. The rate of decrease for the Lebanese women was 0.2 SI units per year for the premenopausal period, and 0.7 SI units per year for the postmenopausal period. CONCLUSION: The age-related female, Lebanese reference curve was significantly different from the American and the European reference curves used by the manufacturer. Therefore, the use of our standardized reference data instead of the proposed US or European database reduces the risk of overestimating osteoporosis in the Lebanese population. The impact of our results on the prevalence of osteoporotic fracture in Lebanon has to be evaluated later on.

Osteoporosis: combination therapy for better or worse.

Osteoporosis is a condition that is associated with an increased susceptibility for fractures. In the past few years, several drugs have become available that can reduce the incidence of fractures in patients with osteoporosis. Since these drugs work through different cellular mechanisms, combining agents of different classes may have an additive or multiplicative effect on fracture risk reduction. Combination treatments that have been evaluated in clinical trials include bisphosphonates with estrogen, raloxifene or PTH/ bisphosphonates and PTH/ estrogen. In general, these trials have shown increases in bone mineral density over that observed with each agent alone. However, whether anti-fracture efficacy is improved, or worsened remains to be established. This article reviews the combination treatments that have been evaluated in clinical trials, with a discussion of the potential benefits and risks that those treatments entail. Integrating safety and cost issues will eventually determine whether those combinations will become the standard of care.

Dental treatment for children under general anaesthesia in day care facilities at a London dental hospital.

Day-stay facilities are gaining in popularity in general surgery, especially in surgery for children. In dentistry, day-stay care has been shown to be of great value for the treatment of specific groups of child patients, including handicapped and those too young to tolerate treatment with local anaesthetic alone. The present study considered the characteristics of 103 patients attending for treatment in the day-care facilities of the Eastman Dental Hospital, the morbidity of the technique and the acceptability of the service to those using it. Of the 103 patients, 46 were seen in the unit because they required minor oral surgery and 22 because of particular problems with management. Ninety-four patients had one or more symptoms following treatment. In at least 53 cases this related to the treatment and not to the anaesthetic. Despite a cost to the families in terms of money and time, the service proved acceptable to almost all of those who used it.