Clinical Briefs

By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville; Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.

Incidentalomas:It's All In Your Head

One of the downstream "consequences" of our ever more-sophisticated quiver of diagnostic arrows—CT, MRI, etc.—is the discovery of incidental findings. Sometimes these "incidentalomas" are important new findings that are ultimately lifesaving. Most often, however, the findings are benign entities which sometimes nonetheless require additional follow-up and added expense.

Vernooij, et al performed MRI of the brain on 2000 persons who are participating in the population-based Rotterdam Study. This study group is comprised of persons age 45 or greater (mean age = 63 years.). All MRIs were read by one of two reviewers, neither of whom had clinical information about the subjects.

The most common incidental finding was asymptomatic ischemic CVA (7.2%). Aneurysms were the next most frequent (1.8%), most of which were <7 mm in size. Benign brain tumors were almost as common as aneurysms (1.6%), most of which were meningiomas.

It is generally recommended that asymptomatic meningiomas be followed for growth, even though most will not require any intervention. Aneurysms of the size discovered in this trial also generally do not merit intervention. Secondary stroke prevention strategies (eg, ASA, clopidogrel) are predicated upon a pre-existing symptomatic stroke or TIA; little guidance is available as to the propriety of secondary stroke prevention driven by incidentally identified CVA. Outcomes follow-up of incidentalomas will help guide future management strategies.

Vernooij MW, et al. N Engl J Med. 2007;357:1821-1828.

Skin Cancer Screening: Our Patients Want It!

The statistics of skin cancer (Sk-Ca) are stark: not only does Sk-Ca overall outnumber all other cancers combined in the US, melanoma diagnosis is anticipated in up to 60,000 individuals in the US in 2007. Since only modest progress in survival for melanoma sufferers has been made, we must rely upon early diagnosis to make an impact.

In 2006, the National Center for Health Statistics reported that for adults over age 18, only 14.5% reported ever undergoing screening for skin cancer; only 8% said they had had a "recent" skin cancer screen. Further insights come from this study performed at University of Miami in 2006. Questionnaires given to patients seeing primary care and dermatology health professionals included whether patients received Full Body Skin Examination, if they would be embarrassed to receive such an examination, if their PCP should perform FBSE regularly, and if it was done, had the clinician performed it with thoroughness.

Only 20% of PCP patients reported regular FBSE, with slightly fewer women than men. More women reported feeling embarrassed by FBSE, but still the majority did not report embarrassment.

Sk-Ca screening is different than almost all other cancer screenings, hence, patient perception of the frequency of screening may be a marked underestimate. In any case, it is clear that patients endorse Sk-Ca screening, and that it may be necessary to either increase our frequency of FBSE, or make our involvement in the process more evident to our patients.

Rodriguez GL, et al. J am Acad Dermatol. 2007;57:775-781.

Bell's Palsy: Steroids, Acyclovir, Both, or Neither?

Of the thousands of persons afflicted each year with Bell's Palsy, the majority will recover without sequelae. As many as 30%, however, are left with some degree of facial paresis, pain, or both. Best evidence supports an etiologic role for herpes virus infection, although vascular and inflammatory disorders have also been implicated. Based upon the putative herpes virus etiology, coupled with the belief that perineural swelling contributes to nerve palsy, it has been commonplace to treat with steroids, antivirals, or both. The evidence supporting such practice is not robust. Indeed, a Cochrane review found insufficient evidence to endorse the use of either intervention. Sullivan, et al now publish the results of a Department of Health (England)-commissioned study to ascertain the effects of prednisolone (PRED), acyclovir (ACYC), or both in Bell's palsy (BELL).

Scottish patients (n=551) with BELL of duration <72 hours were randomized to PRED, ACYC, both, or placebo. The proportion of patients who recovered full facial function was evaluated at 3 and 9 months after intervention.

At 3 months, there was a significant difference in full recovery for patients who received PRED compared to those who did not (83% vs 63.6%) which persisted at 9 months (94.4% vs 81.6%). No evidence of benefit was seen in those receiving ACYC, whether in comparison to placebo, or when added to PRED. This is the largest study on treatment of Bell's palsy, and supports only the utilization of PRED.

Sullivan FM, et al. N Engl J Med. 2007;357:1598-1607.