Sub-clinical Cushing's syndrome in patients with adrenal gland incidentalomas. Pitfalls in diagnosis and management

Widespread use of contemporary imaging techniques (ultrasound, computerized axial tomography, and magnetic resonance imaging scans) have led to the incidental discovery of asymptomatic adrenal neoplasms with increasing frequency. Patients with such adrenal "incidentalomas" typically have no clinical manifestations of adrenal cortical hyperfunction at the time of discovery. We have studied 122 patients with asymptomatic adrenal masses ranging in size from 2 to 7 cm in diameter from 1978 to 1988. Selected patients, after adrenal metastases, pheochromocytoma, myelolipomas, and cysts were ruled out, were further evaluated for adrenal cortical hyperfunction by measuring urinary 17-hydroxysteroids, 17-ketosteroids, and free cortisol, serum A.M., P.M. cortisol, and plasma ACTH levels. These values were also measured before and after dexamethasone suppression. NP-59 adrenal scintiscans were performed on all patients. Six patients were identified with sub-clinical Cushing's syndrome. Baseline cortisol levels were normal in each of these patients. Loss of diurnal rhythm appeared to be the most sensitive indicator of abnormal adrenal cortical function. When adrenalectomy is performed in such patients, especially when contralateral adrenal gland suppression is evidenced by NP-59 scanning or other biochemical assessment, perioperative steroids should be administered in a manner similar to that used for patients with symptomatic Cushing's syndrome. Unilateral adrenalectomy in a patient with an asymptomatic adrenal adenoma, insufficiently studied, may result in Addisonian crisis.     

Comparison of Johnson Anti-Shear Accessory and Standard Dynamometer Attachment for Anterior and Posterior Tibial Translation during Isometric Muscle Contractions

The purpose of this study was to compare the effectiveness of the Johnson Anti-Shear Accessory (JASA) and the standard dynamometer accessory (SDA) in controlling tibial translation for isometric knee flexion and extension exercise on the Cybex(R) II. The subject was a 26-year-old male with known anterior cruciate ligament (ACL) deficiency of the left knee. The subject performed maximum isometric muscle contractions for JASA and SDA conditions. Medial-lateral roentgenograms were obtained while the subject maintained isometric knee flexion and extension muscle contractions at three positions of knee flexion. JASA and SDA trials were analyzed for one extension position and one flexion position. The authors compared JASA and SDA conditions for magnitude of contact pad force and for degree of tibial translation evidenced on the roentgenograms. Tibial translation was greater and contact pad force was less for the SDA condition than the JASA condition. The results suggest the JASA is useful in protecting ACL surgical reconstructions, the partially torn ACL, and secondary supporting structures of the knee as patients perform isometric exercise on Cybex instrumentation. J Orthop Sports Phys Ther 1990;11(11):547-553.     

Modified Allen pictures to assess amblyopia in young children

To produce a test of visual acuity for young children that is more sensitive to amblyopia than current preschool vision tests, the authors surrounded four Allen pictures with "crowding" bars. This modified Allen test was evaluated by measuring acuity of amblyopic children (n = 28) and children (n = 10) and adults (n = 5) with normal eyes. Mean acuities of amblyopic eyes for the modified pictures was 0.8 octaves or nearly three logMar Snellen lines poorer than for the isolated pictures. For nonamblyopic and normal eyes modified picture acuity averaged 0.1 to 0.4 octaves poorer than isolated picture acuity. Average acuities of amblyopic eyes (n = 22) for the modified pictures agreed with line letter acuities. These results suggest that the modified picture test induces contour interaction similar to that of line letter tests, and thus, is a more sensitive test of amblyopia in the preschool child than isolated symbols.     

α1B- but not α1A-adrenoceptors mediate inositol phosphate generation

Summary We used novel highly subtype-selective antagonists to study whether _1A- and/or _1B-adrenoceptors mediate the stimulation of inositol phosphate generation by noradrenaline in rat cerebral cortex. Phentolamine (10 M) and prazosin (100 nM) completely abolished the stimulated inositol phosphate generation. The _1A-selective antagonists 5-methyl-urapidil (100 nM) and (+)– and (–)-niguldipine (10 nM) caused only weak inhibition or none at all although these concentrations occupied _1A-adrenoceptors almost completely. In contrast, pretreatment with the irreversible _1B-selective chloroethylclonidine reduced the noradrenaline-stimulated inositol phosphate generation by 76 ± 8%. These data demonstrate that _1B-adrenoceptors couple to inositol phosphate generation; the signal transduction system of _1A-adrenoceptors remains unclear. Send offprint requests to G. Gross at the above address     

Crack users: the new AIDS risk group?

Crack cocaine, a smokable form of cocaine hydrochloride, is now widely available in American inner cities. Reports of high rates of unprotected sexual activity among crack users, coupled with reports of high rates of sexually transmitted diseases (STDs), have raised fears that this population of drug users may soon be contracting and disseminating sexually transmitted HIV. In a study of 205 black adolescent crack users conducted in Oakland and San Francisco, California, 101 respondents (49% of the sample) who reported using crack in combination with sexual activity were examined. Those respondents who reported having a history of one or more STD were compared using discriminant analysis (DA). A successful discrimination (canonical correlation = 0.61, p = 0.000) identified five variables that distinguished those with a STD history from those with no STD history: gender (being female) (p = 0.000), frequency of marijuana use (p = 0.005), response to the question; "Do you plan for sex or does it just happen?" (p = 0.002), response to the statement, "I use drugs to get away from my problems" (0.029), and response to the question, "Do you agree that sex doesn't feel as good when you use a condom?" (p = 0.006). The selection of these variables was thought to represent an underlying passivity in the way that crack users who combine crack use with sex approach sexual activity.     

Severity adjustment for length of stay: is it always necessary?

OBJECTIVE: Severity adjustment is an oft-cited requirement when comparing physicians or medical delivery systems. Each application of severity adjustment, however, has to be tested to validate the need, the method, and its value. We examined the value of severity adjustment for identifying physician outliers when studying length of stay in the hospital. DESIGN: We compared the placement of physicians in an outlier category using a severity-adjusted average length of stay (SLOS) index with their placement using the unadjusted average length of stay (ALOS). Changes in placement of the list were validated by the utilization review coordinators. SETTING: A 614-bed tertiary-care university teaching hospital. SUBJECTS: We analyzed 11,146 discharges from 138 physicians in 1992. RESULTS: The mean ALOS +/- standard deviation was 9.05 + 4.50 days, and the SLOS Index was 7.56 +/- 3.06. There were 120 inliers, 6 high outliers, and 12 low outliers by the ALOS method. Using the SLOS index, 27 of 138 physicians had their categories changed from inlier to outlier or from outlier to inlier. The difference in group changes was more significant for those going from outlier to inlier status (8/120 vs 6/18; P < .001). The patients of the six physicians whose status changed from outlier to inlier status were sicker, as indicated by the comorbidity, complications, and manifestations of disease processes score. The utilization reviewers validated the status changes in 8 of 14 instances. CONCLUSIONS: Severity-adjusted length of stay by the SLOS index appears to provide a more accurate measure than the unadjusted ALOS. The changes, however, were small. It is not clear that the added effort is worthwhile.