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thin sections through the adrenals A noncontrast CT should be followed by a CT scan using nonionic contrast, which reduces the risk catecholamine release from a pheochromocytoma Glucagon should not be used during scanning, since it can provoke hypertensive crisis; similarly, intravenous contrast can precipitate hypertensive crisis, particularly in patients whose hypertension is uncontrolled MRI scanning has the advantage of not requiring intravenous contrast dye; its lack of radiation makes it the imaging of choice during pregnancy and childhood On T2-weighted MRI, adrenal tumors that are hyperintense relative to liver have an increased likelihood of being pheochromocytomas Both CT and MRI scanning have a sensitivity of about 90% for adrenal pheochromocytoma and a sensitivity of 95% for adrenal tumors over 05 cm in diameter However, both CT and MRI are less sensitive for detecting recurrent tumors, metastases, and extra-adrenal paragangliomas If no adrenal tumor is found, the scan is extended to include the entire abdomen, pelvis, and chest 2 Nuclear imaging A whole-body [123I]m-Iodobenzylguanidine ([123I]mIBG) scan can localize tumors with a sensitivity of 85% and a specificity of 99% It is less sensitive for MEN 2A- or MEN 2B-related pheochromocytomas Preoperative [123I]mIBG scanning is not usually required to confirm that a unilateral adrenal mass is a pheochromocytoma in a patient with classic clinical and biochemical presentation Preoperative whole-body [123I]mIBG scanning can be useful when the CT scan cannot locate a suspected pheochromocytoma, making a paraganglioma more likely; it can also be useful when the CT scan is ambiguous for pheochromocytoma It is prudent to perform a whole-body [123I]mIBG scan about 3 months postoperatively to determine if metastatic or recurrent tumor is present Drugs that reduce [123I]mIBG uptake should be avoided, including tricyclic antidepressants and cyclobenzaprine (6 weeks), amphetamines, nasal decongestants, phenothiazines, haloperidol, diet pills, labetalol, and cocaine (2 weeks) Somatostatin receptor imaging using 111In-labeled octreotide is only 25% sensitive for detecting an adrenal pheochromocytoma However, 111In-labeled octreotide scanning is quite sensitive for detecting extra-adrenal pheochromocytomas (paragangliomas) and metastatic pheochromocytomas, sometimes locating tumors that were missed by [123I]mIBG scanning PET scanning usually detects tumors using 18F-labeled deoxyglucose or 18F-labeled dopamine, and may demonstrate tumors that are not visible on [123I]mIBG scanning Combining PET scan with noncontrast CT produces a PET/CT fusion scan with exceptional sensitivity.

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The FSF is concerned with much more than just supporting the development of free software. The FSF seeks to support and foster an environment that encourages the sharing of ideas. In this context, users of software have the freedom to examine the source code of the software programs they use, can extend them if they wish, and are obliged to share their source code additions with the community. Under this model, no one has the right to restrict the dissemination of knowledge by restricting the availability of source code.12 This movement stands in direct contrast to the commercial software industry. This industry views software as the property of the company that created it, and is therefore closed. Under this scheme, software delivered in binary form does not include its source code, or contains restrictions on the source code s use and dissemination; licensing agreements prohibit sharing the source code with the outside user community. In recent years, this view has changed as seen in Apple s adoption of many open source ideals and its use and support of the Darwin operating system.

The purpose of rubella vaccination is to prevent transmission to the fetus Immunization is recommended for all adults but particularly for women of childbearing age not previously immunized Although persons born before 1957 are considered immune, this is not an acceptable criterion of immunity for women who could become pregnant Thus, women of childbearing age, regardless of birth year, should have rubella immunity checked and should be vaccinated if they lack evidence of antibody They should be counseled not to become pregnant within 4 weeks of immunization Women who are already pregnant and lack immunity should be vaccinated in the postpartum period In addition, both male and female hospital workers who may be exposed to patients with rubella or who might have contact with pregnant patients should be immunized A single immunization is given MMR trivalent vaccine is recommended, but if immu-

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