Biochemical diagnosis of pheochromocytoma: which test is best?

Context  Diagnosis of pheochromocytoma depends on biochemical evidence of catecholamine production by the tumor. However, the best test to establish the diagnosis has not been determined. Objective  To determine the biochemical test or combination of tests that provides the best method for diagnosis of pheochromocytoma. Design, Setting, and Participants  Multicenter cohort study of patients tested for pheochromocytoma at 4 referral centers between 1994 and 2001. The analysis included 214 patients in whom the diagnosis of pheochromocytoma was confirmed and 644 patients who were determined to not have the tumor. Main Outcome Measures  Test sensitivity and specificity, receiver operating characteristic curves, and positive and negative predictive values at different pretest prevalences using plasma free metanephrines, plasma catecholamines, urinary catecholamines, urinary total and fractionated metanephrines, and urinary vanillylmandelic acid. Results  Sensitivities of plasma free metanephrines (99% [95% confidence interval {CI}, 96%-100%]) and urinary fractionated metanephrines (97% [95% CI, 92%-99%]) were higher than those for plasma catecholamines (84% [95% CI, 78%-89%]), urinary catecholamines (86% [95% CI, 80%-91%]), urinary total metanephrines (77% [95% CI, 68%-85%]), and urinary vanillylmandelic acid (64% [95% CI, 55%-71%]). Specificity was highest for urinary vanillylmandelic acid (95% [95% CI, 93%-97%]) and urinary total metanephrines (93% [95% CI, 89%-97%]); intermediate for plasma free metanephrines (89% [95% CI, 87%-92%]), urinary catecholamines (88% [95% CI, 85%-91%]), and plasma catecholamines (81% [95% CI, 78%-84%]); and lowest for urinary fractionated metanephrines (69% [95% CI, 64%-72%]). Sensitivity and specificity values at different upper reference limits were highest for plasma free metanephrines using receiver operating characteristic curves. Combining different tests did not improve the diagnostic yield beyond that of a single test of plasma free metanephrines. Conclusion  Plasma free metanephrines provide the best test for excluding or confirming pheochromocytoma and should be the test of first choice for diagnosis of the tumor.      

Paper or screen,mother tongue or English: which is better? A randomized trial

Context  To compare family physicians' ability to retain information when reading a review article on paper vs on screen, and in their mother tongue vs in English. Methods  Randomized trial of 114 Scandinavian family physicians who read a review article in October or November 2000 from the Journal of Trauma for 10 minutes either on paper and in English, on screen and in English, on paper in their mother tongue, or on screen in their mother tongue. To assess comprehension, they immediately completed a questionnaire with 6 open questions about 13 key facts from the review article. Sum score was on a scale from 0 (no correct answers) to 13 points (all questions answered correctly). Results  There was no significant difference between readers of paper vs screen versions, with a median (interquartile range [IQR]) of 4 (2-6) vs 4 (2-5), respectively (P = .97). Physicians who read in their mother tongue scored significantly higher than those who read in English, with a median (IQR) of 4 (3-6) vs 3 (2-4) (P = .01). Conclusion  The medium (paper vs screen) did not influence the ability of family physicians to retain medical information. They best retained medical information when reading in their mother tongue.      

High cholesterol levels: is mass screening the best option?

Individuals with a high cholesterol level (greater than 6.5 mmol/L) are at a relatively high risk of developing coronary heart disease in the future and an important part of any programme to prevent coronary heart disease is the identification and treatment of these individuals. Mass screening can identify those who are at an increased risk but the likely benefits and costs of such a programme have not been assessed adequately. Before such a method is promoted, we need to know: how well it detects high-risk individuals (yield); what reductions in the risk of coronary heart disease can be expected in those who are screened as "positive"; what adverse effects screening may have on those who are screened as "negative"; and what the logistics and costs (both to those who are screened and to the community as a whole) are. Until we know this information the urge to promote mass screening for cholesterol levels should be restrained, and only those who are at high risk of coronary heart disease should be selected for the determination of their cholesterol levels.     

What is the best operative practice for small benign parotid pleomorphic adenoma?

Most surgeons will reduce the risk of recurrence and permanent facial nerve dysfunction with PSP for PPA with dissection and control of the facial nerve. High volume, very experienced parotid surgeons can offer ECD with the expectation of less transient facial nerve dysfunction, Frey's syndrome, and numbness. Long-term recurrence rates await further reports.     

How can Australia do better for Indigenous health?

Respect, tolerance and trust in Aboriginal and Torres Strait Islander people are needed from government to improve the health and wellbeing of Indigenous Australians.     

Which is the best peri-operative anti-coagulative therapy of transverse sinus stenting for refractory IIH?

Treatment of refractory idiopathic intracranial hypertension (IIH) is a challenging problem. We reported a refractory IIH patient who manifested with typical intracranial hypertensive symptoms successfully treated with endovascular stent implantation. Pre-operative CSF opening pressure is 36 cmH2O. Cerebral angiography demonstrated a stenotic lesion located at the right transverse sinus (TS). The stenotic TS returned to its normal caliber and the pressure gradient deceased from 36 mmHg to 4 mmHg after the stent placement. The intracranial hypertensive symptoms resolved and one month later, the CSF opening pressure decreased to 14 cmH2O.