The association of Cushing's disease and primary empty sella turcica.

The empty sella turcica is defined as the extension of the subarachnoid space toward the intrasellar region with displacement of the pituitary towards the posteroinferior wall. By autopsy studies, the incidence in the general population is around 20%. The association of Cushing's disease (CD) and empty sella has been infrequently reported. In our group, from a total of 68 patients with CD studied by magnetic resonance imaging (MRI), we found the presence of a primary empty sella syndrome (ESS) in 11 (16%). Of these, 9 had partial and 2 total ESS, and in four of them a microadenoma could be identified. Remission, ascertained by subnormal postoperative cortisol levels in blood and/or urine was obtained in 5 of 6 patients operated on by the transphenoidal route. Following surgery, 2 patients presented cerebrospinal fluid (CSF) leakage, 2 diabetes insipidus, and 2 some form of hypopituitarism, figures apparently higher than in non-ESS patients with CD. Ketoconazole was indicated as second line treatment in 2 patients and as primary therapy in 4, resulting in normal urinary free cortisol (UFC) values, with no complications. The relationship of ESS and CD is probably fortuitous given that the frequency of ESS in the general population is similar. Although in empty sella both surgery and radiotherapy seem to have greater risk of complications, surgery remains the first line treatment. Nevertheless, chronic treatment with ketoconazole could be a useful first choice, particularly when no adenoma is seen, or in those who have contraindications for surgery.

[Diagnostic imaging in Cushing's disease and its correlation with postsurgical clinical course]. / Diagnóstico por imágenes en la enfermedad de Cushing y su correlación con la evolución postquirúrgica.

UNLABELLED: The purpose of this paper was to assess the accuracy of computed tomography (CT) and magnetic resonance (MR) in the preoperative identification of corticotropin-secreting pituitary adenomas and to evaluate the concordance with the postoperative outcome. A total of 44 images of patients with Cushing's disease were retrospectively taken into consideration; 23 CT and 29 MR were evaluated. Patients were subdivided into remission or persistence, following the postoperative outcome and biochemical tests. In 13 out of 23 CT performed, an adenoma was found, the remaining 10 being negative. TC sensitivity was 56.5%. Twenty five MR were positive and 4 were negative. The overall sensitivity of MR in detecting ACTH-secreting adenoma was greater (86.0%, P: 0.0373, after Yates correction). After operation, 31 patients (70.5%, Cl 0.70 +/- 0.13) were considered to be in remission (27 total remission and 4 partial remission); 23 had had preoperative visualization of the pituitary tumor and 8 negative neuroradiological evaluation. Thirteen patients had persistence of disease as shown by sustained hypercotisolism in biochemical tests. In 11 of these patients, an adenoma had been preoperatively identified whereas in the remaining 2 no evidence of tumor lesion had been detected. An histologically proven tumor was found in 33 patients but findings were negative in the remaining 11 cases. Lack of histological evidence of an ACTH-secreting adenoma was more frequent in patients with persistent hypercortisolism (P < 0.0078). IN CONCLUSION: 1) MR seems to be more sensitive than CT for detecting ACTH-secreting adenomas (P: 0.037, after Yates correction); 2) no relationship was disclosed between the absence of imaging signs of adenoma and the postsurgical outcome; 3) the remission rate was significantly higher in patients with positive than in those with negative histological findings.

Social equity and access to the World Wide Web and E-mail: implications for design and implementation of medical applications.

INTRODUCTION: The distribution and types of Internet connectivity will determine the equity of access by patient populations to emerging health technologies. We sought to measure the rates, types, and predictors of access in a patient population targeted for Web-based medical services. METHODS: Design. Cross sectional in-person interview. Setting. Emergency department of a large urban pediatric teaching hospital. Subjects. Primary caretakers of patients or patients at least 16 years old. Procedure and measures. Subjects were asked about access to e-mail and the Internet as well as about willingness to use and concerns about Web-based services. Views of equity and access and sociodemographic data were also elicited. RESULTS: 132 subjects were enrolled in the study. Of respondents, 67.2% use a computer and 36.4% can access the Internet or e-mail from home. Including Internet connections and/or e-mail accounts at work, school and public libraries, 50.7% of the sample has access. Forty percent of families have e-mail accounts. The rate at which families have connectivity is primarily correlated with income (r = 0.6, p < 0.01). At all income levels, rates of access to the World Wide Web are higher than to e-mail. White patients are much more likely to have e-mail (OR 5.0, 95% CI 2.4-10.8) and Web access (OR 3.6, 95% CI 1.7-7.5). CONCLUSIONS: Connectivity is directly correlated with income and distributed unevenly across racial and ethnic groups. World Wide Web access is more prevalent than e-mail accounts, and both are often obtained outside the home. Design of health applications should account for these attributes of patient access.

Development of Graves' disease nine years after total thyroidectomy due to follicular carcinoma of the thyroid.

We report a 49-year-old woman with Marfan syndrome who underwent total thyroidectomy for follicular carcinoma. The patient was given 100 mCi of radioactive iodine (131I) followed by levothyroxine (LT4) 0.2 mg/day after surgery. The subsequent five total body scans were negative and thyroglobulin (TG) measurements ranged between undetectable levels to 12 ng/mL. Nine years after thyroidectomy the patient developed bilateral exophthalmos with markedly positive thyroid-stimulating immunoglobulins (TSI), indicating the presence of Graves' disease. TG levels increased and concurrently pulmonary metastases that did not concentrate radioiodine at tracer doses, were diagnosed. Due to these metastatic lesions, the patient received a therapeutic dose of 150 mCi of 131I 1 month after LT4 withdrawal, and a total body scan was made 10 days later. Slight uptake of 131I was found in the right side of the neck, whereas predominant uptake occurred in the right lung base. We suggest that the elevated TSI played a role in the growth of metastases.