Enhanced self-efficacy after a self-management programme in pituitary disease: a randomized controlled trial

CONTEXT

Patients with pituitary disease report impairments in Quality of Life (QoL) despite optimal biomedical care. Until now, the effects of a self-management intervention (SMI) addressing psychological and social issues for these patients and their partners have not been studied.

OBJECTIVE

To examine the effects of a SMI i.e. Patient and Partner Education Programme for Pituitary disease (PPEP-Pituitary).

DESIGN AND SUBJECTS

A multicentre randomized controlled trial included 174 patients with pituitary disease, and 63 partners were allocated to either PPEP-Pituitary or a control group. PPEP-Pituitary included eight weekly sessions (90 min). Self-efficacy, bother and needs for support, illness perceptions, coping and QoL were assessed before the intervention (T0), directly after (T1) and after six months (T2). Mood was assessed before and after each session.

RESULTS

Patients in PPEP-Pituitary reported improved mood after each session (except for session 1). In partners, mood only improved after the last three sessions. Patients reported higher self-efficacy at T1 (P = 0.016) which persisted up to T2 (P = 0.033), and less bother by mood problems directly after PPEP-Pituitary (P = 0.01), but more bother after six months (P = 0.001), although this increase was not different from baseline (P = 0.346). Partners in PPEP-Pituitary reported more vitality (P = 0.008) which persisted up to T2 (P = 0.034). At T2, partners also reported less anxiety and depressive symptoms (P ≤ 0.014).

CONCLUSION

This first study evaluating the effects of a SMI targeting psychosocial issues in patients with pituitary disease and their partners demonstrated promising positive results. Future research should focus on the refinement and implementation of this SMI into clinical practice.

MANAGEMENT OF ENDOCRINE DISEASE: Quality of life tools for the management of pituitary disease

BACKGROUND

In the last few years, quality of life (QoL) has become an outcome measure in patients with pituitary diseases.

OBJECTIVE

To describe the available data on QoL impairment evaluated with questionnaires in patients with pituitary diseases.

DESIGN

Critical review of the pertinent literature and pragmatic discussion of available information.

METHODS

Selection of relevant literature from PubMed and WOK, especially from the last 5 years and comprehensive analysis.

RESULTS

QoL is impaired in all pituitary diseases, mostly in acromegaly and Cushing's disease (similar to other causes of Cushing's syndrome), but also in non-functioning pituitary adenomas and prolactinomas, especially in the active phase of the disease. Nevertheless, even after endocrine 'cure', scores tend to be below normative values, indicative of residual morbidity after hormonal control. The presence of hypopituitarism worsens subjective QoL perception, which can improve after optimal substitution therapy, including recombinant human growth hormone, when indicated.

CONCLUSIONS

To improve the long-term outcome of pituitary patients, helping them to attain the best possible health, it appears desirable to include subjective aspects captured when evaluating QoL, so that the affected dimensions are identified and if relevant treated. Additionally, being aware that treatment outcome may not always mean complete normalisation of physical and mental issues related to QoL can be a first step to adaptation and conforming to this new status.

Pituitary stalk lesions: systematic review and clinical guidance

The spectrum of pituitary stalk (PS) pathology is vast, presenting a diagnostic challenge. Published large series of PS lesions demonstrate neoplastic conditions are most frequent, followed by inflammatory, infectious and congenital diseases. Inflammatory pathologies however, account for the majority of PS lesions in published small case series and case reports. Physicians must be familiar with the major differential diagnoses and necessary investigations. A comprehensive history and thorough clinical examination is critical. Although magnetic resonance imaging of the PS in disease is nonspecific, associated intracranial features may narrow the differential diagnosis. Initial investigations include basic pathology and computer tomography imaging of the neck, chest, abdomen and pelvis. Further investigations should be guided by the clinical context. PS biopsy should be considered when a diagnosis is regarded essential in centres where an experienced neurosurgeon is available. Treatment is dependent on the underlying disease process and may necessitate pituitary hormone replacement.

The development and validation of the Leiden Bother and Needs Questionnaire for patients with pituitary disease: the LBNQ-Pituitary

BACKGROUND

Patients report persisting impairment in quality of life (QoL) after treatment for pituitary disease. At present, there is no questionnaire to assess (a) whether patients with pituitary disease are bothered by these consequences, and (b) their needs for support.

OBJECTIVE

To develop and validate a disease-specific questionnaire for patients with pituitary disease which incorporates patient perceived bother related to the consequences of the disease, and their needs for support.

METHODS

Items for the Leiden Bother and Needs Questionnaire for patients with pituitary disease (LBNQ-Pituitary) were formulated based on results of a recent focus group study (n = 49 items). 337 patients completed the LBNQ-Pituitary and six validated QoL questionnaires (EuroQoL-5D, SF-36, MFI-20, HADS, AcroQol, CushingQoL). Construct validity was examined by exploratory factor analysis. Reliabilities of the subscales were calculated with Cronbach's alphas, and concurrent validity was assessed by calculating Spearman's correlations between the LBNQ-Pituitary and the other measures.

RESULTS

Factor analyses produced five subscales (i.e., mood problems, negative illness perceptions, issues in sexual functioning, physical and cognitive complaints, issues in social functioning) containing a total of 26 items. All factors were found to be reliable (Cronbach's alphas all ≥.765), and the correlations between the dimensions of the LBNQ-Pituitary and other questionnaires (all P ≤ .0001) demonstrated convergent validity.

CONCLUSIONS

The LBNQ-Pituitary can be used to assess the degree to which patients are bothered by the consequences of the pituitary disease, as well as their needs for support. It could also facilitate an efficient assessment of patients' needs for support in clinical practice. We postulate that paying attention to needs for support will lead to optimal patient care (e.g., improvement in psychosocial care), and positively affect QoL.

[Central Thyroid Disorders]

Vast majority of thyroid function disturbances have primary (peripheral) etiology due to thyroid gland disorders. Rarely, dysfunction of central regulatory structures, hypothalamus and pituitary, can be a cause of both, hyperthyroidism and hypothyroidism. Despite being very rare, it is important to be aware of them not to misdiagnose their etiology. Early and correct etiological diagnosis is necessary for proper cure and decrease of morbidity and mortality of affected patients. Present review article summarizes basics and specific features of central disturbances of thyroid function, their clinical signs, diagnosis, differential diagnosis and treatment.Key words: hypothalamus - hyperthyroidism - hypothyroidism - pituitary - thyrotropinoma.

Intrasellar abscess following pituitary surgery

PURPOSE

Intrasellar abscess is an uncommon cause of mass lesions in the sella turcica. Few cases have been reported in the literature, and much remains unknown about the etiology and diagnosis of these lesions. We sought to review a series of patients with intrasellar abscess encountered at our institution and identify defining characteristics of their presentation and management.

METHODS

We conducted a retrospective chart review for intrasellar infection cases associated with a mass lesion. Included cases had clear demonstration of a mass lesion on imaging with subsequent positive microbiological cultures. Clinical presentation, management, post-operative course, neuroimaging, microbiology, and any perturbations in serum pituitary biochemical markers were examined.

RESULTS

All examined patients had a history of antecedent transsphenoidal pituitary surgery within the preceding 10 months. All presented with headaches, three with progressive visual loss, one with meningismus, one with fever in the setting of an active cerebrospinal fluid leak, and one with fever, meningismus, hypotension, and progressive somnolence. No patient presented with acute endocrine abnormalities. A majority did not initially have any diffusion restriction present on MRI, but in one case we were able to track the evolution of diffusion restriction over sequential MRI scans. Two patients had complete resolution of presenting symptoms, while three experienced improvement or stabilization of their neurologic deficit. There were no mortalities.

CONCLUSIONS

Pituitary abscess remains a rare diagnosis that can be difficult to make and to confirm. In our series we found a strong association between culture-positive abscess and recent pituitary surgery. When present, prompt treatment with surgical drainage and aggressive post-operative antibiotics can lead to a favorable outcome.

Hypophysitis

In this article, an overview is presented of hypophysitis in terms of current clinical and experimental findings, with discussion of the anatomic and histopathologic classification of primary hypophysitis and factors associated with secondary hypophysitis. In addition, discusses the pathophysiology, clinical features, management, and prognosis associated with this disease are discussed.

Pituitary abscess in an adolescent girl: a case report and review of the literature

We report the case of a 15-year-old girl who presented with a history of recurrent bitemporal headaches for the last 2 months. In the prior few days, she complained of neck pain, emesis, phonophobia and photophobia, but no fever. Additional symptoms included polydipsia, polyuria and weight gain in the last year. Magnetic resonance imaging (MRI) of the brain demonstrated a cystic sellar and suprasellar mass with peripheral enhancement. Cerebrospinal fluid studies showed pleocytosis. Serum hormone levels were consistent with panhypopituitarism. Transnasal sphenoidotomy was performed, and 2 mL of purulent material was drained, confirming the diagnosis of pituitary abscess. The patient completed 6 weeks of parenteral antibiotics. She improved but continued to require home hormonal replacement therapy. A repeated MRI 3 months later showed abscess resolution. In addition to tumors, pituitary abscess should be considered in children who present with headache and panhypopituitarism, particularly in those who present with signs of meningeal inflammation. Prolonged parenteral antibiotics and surgical drainage are effective.

Primary (autoimmune) hypophysitis: a single centre experience

BACKGROUND

Autoimmune hypophysitis (AH) is a rare autoimmune inflammatory disorder of pituitary gland.

OBJECTIVE

To analyse clinical, hormonal, radiological features and management outcomes of AH.

DESIGN

Retrospective analysis of patients with primary hypophysitis (where secondary causes of hypophysitis were ruled out) was carried out from 2006 to 2012. AH emerged as the most plausible aetiology and the diagnosis of exclusion.

RESULTS

Twenty-four patients with AH (21 females and 3 males) were evaluated. They presented with symptoms of expanding sellar mass (83.3%), symptoms of anterior pituitary hormone deficiencies (58.3%), and diabetes insipidus (16.7%). The anterior pituitary hormonal axes affected were cortisol (75%), thyroid (58.33%) and gonadotropin (50%). All had sellar mass on magnetic resonance imaging, which was symmetrical (91.7%) and homogenously enhancing (91.7%). Stalk thickening, suprasellar extension, loss of posterior pituitary hyperintensity and parasellar T2 dark sign were seen in 87.5, 87.5, 71.5, and 50% respectively. In addition to hormone replacement, five (20.83%) patients underwent trans-sphenoidal surgery, fifteen (62.5%) were watchfully monitored, while four cases (16.67%) received steroid pulse therapy. On follow up imaging, the sellar mass regressed in all, while, stalk thickening was persistent in 13/19 (68.4%) non-operated patients at median follow up of 1 year. Pituitary hormone axis recovery was seen in 10 (41.67%) and was seen in cortisol 10/18 (55.5%) followed by gonadotropin 5/12 (41.67%) axis.

CONCLUSION

Characteristic radiology helps in diagnosis of AH even without tissue diagnosis. Non-operative treatment is the preferred treatment modality. Steroid pulse therapy potentially improves pituitary axis recovery.

Incidentalomas: initial management

Incidentalomas are increasingly common findings on radiologic studies, causing worry for physicians and patients. Physicians should consider the risk of discovering incidentalomas when contemplating imaging. Patients may assume that incidentalomas are cancer, and may not be aware of the radiation risks associated with repeat imaging. Once incidentalomas are detected, appropriate management is dependent on an informed patient's wishes and the clinical situation. Guidelines are provided for the initial management of eight incidentalomas (pituitary, thyroid, pulmonary, hepatic, pancreatic, adrenal, renal, and ovarian). Patients presenting with pituitary incidentalomas should undergo pituitary-specific magnetic resonance imaging if the lesion is 1 cm or larger, or if it abuts the optic chiasm. Thyroid incidentalomas are ubiquitous, but nodules larger than 1 to 2 cm are of greater concern. Worrisome pulmonary incidentalomas are those larger than 8 mm or those with irregular borders, eccentric calcifications, or low density. However, current guidelines recommend that even pulmonary incidentalomas as small as 4 mm be followed. Solid hepatic incidentalomas 5 mm or larger should be monitored closely, and multiphasic scanning is helpful. Pancreatic cystic neoplasms have malignant potential, and surgery is recommended for pancreatic cysts larger than 3 cm with suspicious features. Adrenal lesions larger than 4 cm are usually biopsied. The Bosniak classification is a well-accepted means of triaging renal incidentalomas. Lesions at category IIF or greater require serial monitoring or surgery. Benign or probably benign ovarian cysts 3 cm or smaller in premenopausal women or 1 cm or smaller in postmenopausal women do not require follow-up. Ovarian cysts with thickened walls or septa, or solid components with blood flow, should be managed closely.

Sarcoidosis of the head and neck

Sarcoidosis is a complex disorder that often times involves the head and neck. Despite the presence of strong clinical evidence, tissue diagnosis and imaging is needed for confirmation of the disease. Although typically managed medically, when found in the sinonasal tract or intracranially, it may necessitate the intervention of a rhinologist-skull base surgeon. This article seeks to provide a comprehensive review of head and neck sarcoidosis, as this fascinating disorder often poses a diagnostic and therapeutic challenge. A brief discussion of surgical treatment for pituitary lesions is also provided. Articles from 1997 to 2013 were selected and reviewed by three researchers utilizing the most recent literature regarding sarcoidosis in the head and neck. PubMed searches were conducted using search terms such as "sarcoidosis", "neurosarcoid", and "extra-pulmonary sarcoid", among many others. A large collection of articles was generated and reviewed by the team of authors, and appropriate information was extracted to compose a thorough and expansive review of the subject. 10-15 % of patients with sarcoidosis have head and neck manifestations. Sinonasal and pituitary sarcoidosis presents a diagnostic challenge owing to its non-specific symptoms. Although systemic steroid therapy is often the first time treatment, endoscopic surgery is commonly used to treat advanced pituitary sarcoidosis refractory to medical management. As tissue diagnosis and imaging is key, a multi-disciplinary team approach is advantageous. Our study collates the available literature on head and neck sarcoidosis to provide a comprehensive review of the subject. This provides helpful information to guide all practitioners involved in the care of these challenging patients, namely pathologists, radiologists, otolaryngologists, and skull base surgeons, in the workup and management of head and neck sarcoidosis.

Headache and pituitary disease: a systematic review

Headache is very common in pituitary disease and is reported to be present in more than a third of all patients with pituitary adenomas. Tumour size, cavernous sinus invasion, traction or displacement of intracranial pain-sensitive structures such as blood vessels, cranial nerves and dura mater, and hormonal hypersecretion are implicated causes. The present review attempts to systematically review the literature for any combination of headache and pituitary or hormone overproduction or deficiency. Most data available are retrospective and/or not based on the International Headache Society (IHS) classification. Whereas in pituitary apoplexy a mechanical component explains the almost universal association of the condition with headaches, this correlation is less clear in other forms of pituitary disease and a positive impact of surgery on headaches is not guaranteed. Similarly, invasion into the cavernous sinus or local inflammatory changes have been linked to headaches without convincing evidence. Some studies suggest that oversecretion of GH and prolactin may be important for the development of headaches, and treatment, particularly with somatostatin analogues, has been shown to improve symptoms in these patients. Otherwise, treatment rests on general treatment options for headaches based on an accurate clinical history and a precise classification which includes assessment of the patient's psychosocial risk factors.

Neuroendocrine consequences of traumatic brain injury

PURPOSE OF REVIEW

This article attempts to summarize findings of recent publications addressing the prevalence, effects, and treatment of pituitary hormone deficiency following traumatic brain injury (TBI).

RECENT FINDINGS

A number of recent studies of TBI victims offer larger samples and much longer follow-up times. However, the prevalence of pituitary hormone deficiency continues to vary widely, underscoring the influence of patient selection, differences in endocrine testing, and patient's comorbidities and age. Growth hormone deficiency (GHD) continues to be the most frequently detected type of pituitary dysfunction. Several reports show the influence of GHD on functional outcomes of TBI victims beyond what is predicted by trauma severity. Emerging data support the notion growth hormone (GH) replacement as a useful intervention to improve symptomatology and functional outcomes among adequately selected GH-deficient patients recovering from TBI.

SUMMARY

Pituitary dysfunction is prevalent following TBI. Pituitary dysfunction seems to influence functional outcomes in some patients recovering from brain injury. Adequately selected patients could benefit from hormonal replacement.

Endocrine disease in pregnancy

Endocrine disease is common in pregnancy. Most pre-existing endocrine conditions, if well controlled, have little impact on maternal or fetal morbidity. Uncontrolled endocrine conditions in pregnancy, whether poorly controlled pre-conception or newly diagnosed, are associated with a variety of adverse fetal outcomes and maternal morbidity. Also, transplacental transfer of maternal antibodies can have adverse fetal or neonatal consequences. The initial diagnosis of many conditions is hindered by the overlap of symptoms that occur in normal pregnancy and those that suggest specific endocrine pathologies, and also by the changes in reference ranges for common biochemical measurements that occur as a result of physiological changes in pregnancy. This article summarises the common endocrine disorders in pregnancy and describes how pregnancy can alter their investigation, treatment and ongoing management, as well as the potential effects on the fetus.

A case of idiopathic granulomatous hypophysitis

Granulomatous hypophysitis is a rare pituitary condition that commonly presents with enlargement of the pituitary gland. A 31-year-old woman was admitted to the hospital with a severe headache and bitemporal hemianopsia. Magnetic resonance imaging (MRI) showed an 18 × 10-mm sellar mass with suprasellar extension and compression of the optic chiasm. Interestingly, brain MRI had shown no abnormal finding 4 months previously. On hormonal examination, hypopituitarism with mild hyperprolactinemia was noted. The biopsy revealed granulomatous changes with multinucleated giant cells. We herein report this rare case and discuss the relevant literature.

[Pituitary disorders in patients after traumatic brain injury and radiotherapy]

Traumatic brain injury is an important public health problem all over the world. Cranial radiation is routinely and increasingly used to manage various types of tumors. Both traumatic brain injury and brain radiotherapy are a frequent and overlooked cause of abnormalities in hypothalamic-pituitary axis function or sometimes even of overt pituitary disorders altering patients' health and quality of life. Because clinical manifestations may be subtle and develop insidiously many years after injury or radiotherapy, establishing a correct diagnosis is not always straightforward. Diagnosis of hypopituitarism and accurate treatment of pituitary disorders offers the opportunity to improve mortality and outcome in both groups of patients. The purpose of this paper is to review the pathogenesis, clinical manifestations, diagnosis and treatment of traumatic brain injury- or radiotherapy-induced pituitary disturbances with a special emphasis on the most recent literature.

Pituitary resistance to thyroid hormones: pathophysiology and therapeutic options

Thyroid hormone secretion suppresses the expression of thyroid stimulating hormone (TSH), both of which are strictly controlled by a negative feedback loop between the hypothalamus-pituitary and thyroid. Pituitary resistance to thyroid hormone (PRTH) is defined as resistance to the action of thyroid hormone that is more severe in the pituitary than at the peripheral tissue level. Although the molecular basis of PRTH is not well understood, the clinical issue mainly involves imbalance between the hypothalamus-pituitary and peripheral thyroid hormone responsivity, which may induce peripheral thyrotoxic phenomena. Here, we review the pathogenesis and molecular aspects of PRTH, present a single case with inappropriate TSH secretion suffering from thyrotoxicosis treated with PTU, and discuss the possible choice of therapeutic options to correct the imbalance of thyroid hormone responsivity in both the hypothalamus-pituitary and peripheral tissues.

Pituitary dysfunction following traumatic brain injury or subarachnoid haemorrhage - in "Endocrine Management in the Intensive Care Unit"

Traumatic brain injury and subarachnoid haemorrhage are important causes of morbidity and mortality in the developed world. There is a large body of evidence that demonstrates that both conditions may adversely affect pituitary function in both the acute and chronic phases of recovery. Diagnosis of hypopituitarism and accurate treatment of pituitary disorders offers the opportunity to improve mortality and outcome in both traumatic brain injury and subarachnoid haemorrhage. In this article, we will review the history and pathophysiology of pituitary function in the acute phase following traumatic brain injury and subarachnoid haemorrhage, and we will discuss in detail three key aspects of pituitary dysfunction which occur in the early course of TBI; acute cortisol deficiency, diabetes insipidus and SIAD.