‘Empty sella’ on routine MRI studies: An incidental finding or otherwise?

Background

Empty sella (ES) has been regarded as an incidental finding. Recently, there have been studies documenting association of ES with hormonal and non-hormonal abnormalities. To detect the prevalence of empty sella in routine MRI brain study and to find associations with other diseases.

Methods

A retrospective study was carried out for patients undergoing MRI brain studies in the radiology department of a teaching institution. Patients with ES formed the study group. The rest formed the baseline population. Presence of nine select variables, viz. hormonal disturbances, headache, sensorineural hearing loss, seizures, vertigo, psychiatric disorders, visual disturbances, ataxia and raised intracranial tension, was analyzed amongst the study group, as well as the baseline population. Association of ES and the select variables was analyzed by determining means and proportions and using Chi-square test.

Results

During the study period, a total of 12,414 patients underwent MRI brain studies at our centre. ES was found in 241 (1.94%) patients. The proportion of patients in the ES and non-empty sella groups for each of the variables were as follows: hormonal disturbances (3.31% vs 0.56%, P = .000), headache (8.3% vs 7.4%, P = .596), SNHL (3.7% vs 1.3%, P = .0010), seizure (6.2% vs 13%, P = .002), vertigo (4.6% vs 1.6%, P = .000), psychiatric disorders (4.6% vs 1.3%, P = .000), visual disturbances (2% vs 1.1%, P = .166), ataxia (1.7% vs 1.2%, P = .519) and raised ICT (2% vs 0.5%, P = .002).

Conclusion

Hormonal disturbances, psychiatric disorders, raised ICT and SNHL have been found to be more often associated with ES as compared to general population.     

A cystic hepatic lesion: when to worry?

A 16-year old female presented to hospital with abdominal pain. Features on computed tomography raised the possibility of biliary cystadenoma or cystadenocarcinoma. She underwent a liver resection, and histopathology confirmed a serous biliary cystadenoma. This case is presented to highlight the radiological features of this uncommon pre-malignant condition as well as to summarize a management algorithm for cystic liver lesions.     

Does this patient have an instability of the shoulder or a labrum lesion?

Jolanda J. Luime, MSc; Arianne P. Verhagen, PhD; Harald S. Miedema, MD; Judith I. Kuiper, PhD; Alex Burdorf, PhD; Jan A. N. Verhaar, PhD, MD; Bart W. Koes, PhD

JAMA. 2004;292:1989-1999.

Context  History taking and clinical tests are commonly used to diagnose shoulder pain. Unclear is whether tests and history accurately diagnose instability or intra-articular pathology (IAP).

Objective  To analyze the accuracy of clinical tests and history taking for shoulder instability or IAP.

Data Sources  Relevant studies identified through PubMed, EMBASE, CINAHL, and bibliographies of known primary and review articles.

Study Selection  Studies comparing the performance of history items or physical examination with a reference standard were included. Studies on fibromyalgia, fractures, or systemic disorders were excluded. Of 1449 articles, 35 were eligible, and 17 were selected.

Data Extraction  Data were extracted on study population, clinical tests, reference tests, and outcome. The studies’ methodological quality (patient spectrum, verification, blinding, and replication) was assessed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist.

Data Synthesis  Six tests showed positive likelihood ratios (LRs) and confidence intervals (CIs). Tests favoring the diagnosis for establishing instability included: relocation (LR, 6.5; 95% CI, 3.0-14.0) and anterior release (LR, 8.3; 95% CI, 3.6-19). Tests showing promise for establishing labral lesions included: the biceps load I and II (LR, 29; 95% CI, 7.3-115.0 and LR, 26; 95% CI, 8.6-80.0), respectively, pain provocation of Mimori (LR, 7.2; 95% CI, 1.6-32.0), and internal rotation resistance strength (LR, 25; 95% CI, 8.1-76.0). The apprehension, clunk, release, load and shift, and sulcus sign tests proved less useful. Results should be cautiously interpreted because studies were completed in select populations in orthopedic practice, mostly assessed by the test designers, and evaluated in single studies only. No accuracy studies were found for history taking or for clinical tests in primary care.

Conclusions  Shoulder complaints are frequently recurrent. Instability might cause some of these complaints. Best evidence supports the value of the relocation and anterior release tests. Symptoms related to IAP (labral tears) remain unclear. Most promising for establishing labral tears are currently the biceps load I and II, pain provocation of Mimori, and the internal rotation resistance strength tests.

     

Warfarin or aspirin: both or others?

In general, aspirin is indicated to prevent thrombosis in conditions associated with high shear rates (i.e., atherosclerosis) and warfarin is indicated to prevent thrombosis in conditions associated with stasis (i.e., atrial fibrillation). While aspirin and warfarin should generally not be used together, their combined use is beneficial in selected patients (e.g., some patients with mechanical valve prostheses). Aspirin in a dose of 75-150 mg per day is indicated to prevent vascular events in patients with ischaemic heart disease and also in patients at high risk of ischaemic heart disease. All patients with atrial fibrillation should be considered for oral anticoagulant therapy, with the decision for its use based on an assessment of the balance between the risk of thromboembolism and bleeding. The recommended therapeutic INR (international normalised ratio) range in non-valvular atrial fibrillation is 2.0-3.0. Warfarin is contraindicated in pregnancy, particularly during the first trimester; however, it may still need to be used in the second and third trimesters in patients with mechanical valve prostheses.     

Depression: dispirited or spiritually deprived?

The 20th century has seen a widespread decline in mental health in Western society. One important factor may be the lack of meaning and spiritual fulfilment that is part of our increasingly secular and materialistic society. In medical education and practice, religious issues are often marginalised or 'pathologised", despite consistent evidence from the literature of the protective effect of "religiosity" or "spirituality" on mental and physical health.     

Swallow syncope: reflex or reflux?

A 51-year-old man presented with symptoms of syncope on consuming solid foods. He had a 5 year history of intermittent symptoms on eating only solids and his cardiovascular investigations revealed bradycardia during food ingestion. He was treated by insertion of a pacemaker with cessation of his syncopal symptoms.     

Nuclear war: preventable or inevitable?

Smith reports at length on the fourth meeting of International Physicians for the Prevention of Nuclear War, held in Helsinki in 1984 and attended by 450 doctors from 53 countries. Among the topics addressed by the delegates were the preventability of nuclear war, the threat of nuclear winter, the expenditure on atomic weapons of funds that could be used for health programs, the effects on children of the threat of nuclear conflict, and the danger of accidental nuclear war. The meeting concluded with a letter sent from the conference to the leaders of the United States and the Soviet Union.     

Genetic privacy: orthodoxy or oxymoron?

In this paper we question whether the concept of "genetic privacy" is a contradiction in terms. And, if so, whether the implications of such a conclusion, inevitably impact on how society comes to perceive privacy and responsibility generally. Current law and ethical discourse place a high value on self-determination and the rights of individuals. In the medical sphere, the recognition of patient "rights" has resulted in health professionals being given clear duties of candour and frankness. Dilemmas arise, however, when patients decline to know relevant information or, knowing it, refuse to share it with others who may also need to know. This paper considers the notions of interconnectedness and responsibility to others which are brought to the fore in the genetic sphere and which challenge the primacy afforded to personal autonomy. It also explores the extent to which an individual's perceived moral obligations can or should be enforced.     

Angiogenesis: a curse or cure?

Angiogenesis, the growth of new blood vessels is essential during fetal development, female reproductive cycle, and tissue repair. In contrast, uncontrolled angiogenesis promotes the neoplastic disease and retinopathies, while inadequate angiogenesis can lead to coronary artery disease. A balance between pro-angiogenic and antiangiogenic growth factors and cytokines tightly controls angiogenesis. Considerable progress has been made in identifying these molecular components to develop angiogenesis based treatments. One of the most specific and critical regulators of angiogenesis is vascular endothelial growth factor (VEGF), which regulates endothelial proliferation, permeability, and survival. Several VEGF based treatments including anti-VEGF and anti-VEGF receptor antibodies/agents are in clinical trials along with several other antiangiogenic treatments. While bevacizumab (anti-VEGF antibody) has been approved for clinical use in colorectal cancer, the side effects of antiangiogenic treatment still remain a challenge. The pros and cons of angiogenesis based treatment are discussed.