Macroscopic brain architecture changes and white matter pathology in acromegaly: a clinicoradiological study

The socioeconomic burden of acromegaly

Acromegaly is a rare and insidious disease characterized by chronic excess growth hormone, leading to various morphological changes and systemic complications. Despite its low prevalence, acromegaly poses a significant socioeconomic burden on patients and healthcare systems. This review synthesizes the current state of knowledge on the psychosocial burden, disability, impact on daily life, and cost of acromegaly disease, focusing on the quality of life, partnership, medical care and treatment afflictions, participation in daily activities, professional and leisure impairment, and cost of treatment for acromegaly and its comorbidities. It also examines management strategies, coping mechanisms, and interventions aimed at alleviating this burden. A comprehensive understanding of the extent of the socioeconomic burden in acromegaly is crucial to develop effective strategies to improve treatment and care. Further research is warranted to explore the myriad factors contributing to this burden, as well as the efficacy of interventions to alleviate it, ultimately enhancing the quality of life for patients with acromegaly.

Variables Associated With Body Image Concerns in Acromegaly Patients: A Cross-Sectional Study

Objective

Acromegaly is often characterized by altered physical (including facial) appearance. However, there is little medical or psychological research on body image concerns in patients with acromegaly. The aim of this study was to identify factors influencing the body image distress in patients with acromegaly and to explore the possible effects of stigma on body image concerns.

Design

Cross-sectional study.

Methods

A total of 68 individuals with acromegaly were enrolled in the study. A total of 70 persons with nonfunctional pituitary adenomas were randomly recruited as a healthy control group. Using structured questionnaires, we explored perceived body image using the Body Image Concern Inventory. We also used the Hamilton Anxiety Scale, the Stigma Scale for Chronic Illness, the Brief Illness Perception Questionnaire, and the 36-Item Short-Form Health Survey to evaluate health-associated variables and to analyze factors that affect body image concerns in patients with acromegaly.

Results

Of the 68 participants, 31 were men and 37 women (mean age ± standard deviation: 46.36 ± 12.47 years). The mean body image concern score was 47.49 ± 13.81 for patients with acromegaly and 21.10 ± 7.44 for patients with nonfunctional pituitary adenoma. The difference between the two groups was statistically significant. A multiple stepwise regression analysis showed that the related factors for body image distress were gender (P = 0.001), age at diagnosis (P = 0.01), and internalized stigma (P < 0.001, Adj. R² = 0.756).

Conclusions

People with acromegaly have substantial body image concerns, and these concerns are increased by the stigma associated with this disease; such concerns lead to poor quality of life (QoL). Physicians need to find better ways to control patients' hormone levels, and nurses should provide more information on how to improve body image or find ways to reduce patients' body image distress.

Induction of endoplasmic reticulum stress markers in an acromegaly model

Acromegaly is a growth hormone (GH) excess pathological condition in humans. Acromegaly is associated with somatic disfigurement and a wide range of systemic manifestations such as arthritis, neuropathy, carpal tunnel syndrome, reproductive disorders, metabolic disorders, and gastrointestinal complications. The influence of excess GH on the cellular level could aid in understanding the root causes of acromegaly-related health complications. Previously, we found that GH excess induces DNA damage to somatic cells and reduces the stem cells number and causes premature aging. In this study, an in-depth analysis of the acromegaly RNAseq data revealed the disruption of important biological cellular processes. Gene set enrichment analysis, heatmap, and enrichment analysis of acromegaly RNAseq data revealed induction of endoplasmic reticulum (ER) stress markers in various organs. Interestingly, the induction of ER stress was even more apparent than in aged zebrafish. Splicing of box-binding protein-1 (XBP1) mRNA is a hallmark of ER stress. Therefore, we quantified spliced XBP1 mRNA in different organs of our acromegaly model. Thus, our study emphasizes the importance of ER stress in GH oversecretion, which is important for understanding the health complications of acromegaly.

Personality traits in acromegalic patients: Comparison with patients with non-functioning adenomas and healthy controls

OBJECTIVES

Pituitary diseases may cause psychiatric and personality alterations. We aimed to compare the personality traits of acromegalic patients with those of patients with non-functioning pituitary adenomas and a healthy control group.

DESIGN

Fifty-eight acromegalic patients, 45 patients with non-functioning adenoma, and 40 healthy subjects were enrolled in the study. Cloninger's Temperament and Character Inventory (TCI), Beck Depression Inventory, Beck Anxiety Inventory, and Rosenberg Self-Esteem Scale (RSES) were used to assess personality, depression, anxiety, and self-esteem.

RESULTS

Depression score was higher in acromegaly and non-functioning adenoma groups than healthy controls. RSES scores were similar among the three groups. Regarding the scales of TCI, only novelty-seeking was significantly reduced in acromegaly and non-functioning adenoma than the control group. Pairwise comparisons revealed that the difference was due to the difference between acromegalic patients and controls. Scales of TCI were correlated with depression and anxiety in patients with acromegaly and non-functioning adenoma but not in healthy controls.

CONCLUSION

This study showed that novelty-seeking was reduced in patients with acromegaly. Both the hormonal lack and excess and structural changes can lead to cognitive and personality changes in acromegaly. More studies are needed to be carried out about personality characteristics in pituitary diseases.

Case report: Treatment of psychiatric symptoms for an acromegalic patient with pituitary adenoma

Acromegalic patients always demonstrate a wide range of clinic manifestations, including typical physical changes such as acral and facial features, as well as untypical neuropsychiatric and psychological disturbances. However, there is still a lack of clinical guidance on the treatment for acromegalic patients with psychiatric comorbidities. We therefore share this case to provide a reference for clinicians to manage the acromegalic patients with psychiatric symptoms. This case report describes a 41-year-old male with an 8-year history of acromegaly due to growth hormone-secreting pituitary adenoma, the maximum cross-sectional area of which was 42 mm × 37 mm demonstrated by pituitary magnetic resonance imaging (MRI). The patient received conservative medicine treatment by regularly injecting with Sandostatin LAR 10 mg per month. Two days before admission, he suddenly presented with an acute psychotic episode. In addition to the typical acromegaly-associated changes, his main clinical presentations were olfactory/auditory hallucinations, reference/persecutory delusions, instable emotion and impulsive behavior. Considering the schizophrenic-like psychoses and course features, he was diagnosed with Brief Psychotic Disorder according to Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) after a multidisciplinary consultation and evaluation. He was prescribed Aripiprazole, which had less extrapyramidal symptoms and minimal influence on prolactin elevation, with the dose of 5 mg per day to control the psychiatric symptoms and he responded quite well. At the time of discharge and the follow-up 2 month later, the patient was stable without recurrence of any psychotic symptoms. The levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1) 1 week after discharge were 2.22 ng/mL [normal range (0-2.47 ng/mL)] and 381 μg/L [normal range (94-284 μg/L)], respectively, which were similar to those before the psychotic episode. Results from this report further supported that small dose of Aripiprazole had little influence on hormonal levels and the development of pituitary macroadenoma. This particular case emphasizes the importance for the clinician to master and carefully identify the possible symptoms of mental disorders associated with acromegaly, and also highlights the need for further investigation in more efficient treatment strategies for acromegalic cases with psychiatric comorbidities.

A Longitudinal, Prospective Study to Evaluate the Effects of Treatment on the Inhibitory Control Function After Transsphenoidal Surgery for Pituitary Adenomas

OBJECTIVES

Injured cognitive abilities have been reported in patients with pituitary adenoma. However, to date, few researchers have directly investigated the electrophysiological study of inhibitory control function of pituitary patients both pre- and postsurgery. Thus, this study aimed to identify the factors affecting the inhibitory control function of pituitary patients.

METHODS

Thirty presurgery pituitary patients were recruited and 26 patients of them completed the postsurgery follow-up. Thirty healthy people were recruited for control group. Visual Go/Nogo tasks were carried out by the patients and controls to assess the inhibitory control function before surgery and 6 months after the surgery, respectively. The function of inhibitory control was analyzed with the components of N2 and P3.

RESULTS

Across 3 groups, Nogo stimuli evoked larger frontal-central N2nogo and P3nogo than Go stimuli did. Furthermore, N2d of presurgery patients (-1.14 μV) and postsurgery patients(-0.61 μV) were significantly decreased compared with that of control group (-3.09 μV), F(2, 83) = 13.92, P < .01, whereas no difference was detected between pre- and postsurgery groups. There was no remarkable difference in the amplitude of P3d among the 3 groups, F(2, 83) = 0.19, P > .05. With regard to the amplitude of P3 for Go condition, The P3 amplitude of healthy group (4.38 μV) was larger than both pre- and postsurgery (1.00 μV and 3.01 μV). With regard to the amplitude of P3 for Nogo condition, The P3 amplitude of healthy group (5.25 μV) was larger than both pre- and postsurgery groups (2.35 μV and 4.18 μV).

CONCLUSIONS

These results indicated that presurgery patients showed the dysfunction of inhibition, due to the nerve tissue damage or brain structure alteration caused by the presurgery physical pressure from tumor and abnormal hormone levels. Postsurgery patients showed a tendency toward recovery, but there was no obvious improvement in the inhibitory control function after successful treatments.

Improvement in Attention Processing After Surgical Treatment in Functional Pituitary Adenomas: Evidence From ERP Study

Cognitive abilities are impaired in patients with pituitary adenoma. However, studies on attention processing impairment in preoperative patients and attention processing recovery after transsphenoidal adenomectomy are lacking. The study aims to identify the electrophysiological change that relates to attention processing in pituitary patients before and after treatment. Twenty five preoperative pituitary patients and 25 follow-up postoperative patients were recruited. 27 healthy controls (HCs) were matched to the patients with age, gender, and education. Event-related potentials were used to investigate the attention processing in the preoperative patients, postoperative patients, and HCs. Across three groups, all emotional stimuli evoked P200 components. Compared with the HCs or postoperative patients, the amplitudes of P200 in the preoperative patients were higher. Moreover, The amplitudes of P200 decreased in the postoperative patients, which were similar to that in the HCs. The attention processing was improved after surgery, but no significant differences were detected between the postoperative patients and HCs. Abnormal hormone levels may be relevant to the factor that impair attention processing. Compared with that of the HCs and postoperative patients, the P200 component elicited by negative stimuli is higher in preoperative patients, which may illustrate compensatory activity after attention impairments. Furthermore, these data indicate that improvements in attention processing may be attributed to the amelioration of endocrine disorders. This study shows that the P200 component may be used to diagnose attention processing in preoperative pituitary patients and prove the improvement of attention processing in postoperative patients.

Altered Connectivity of the Frontoparietal Network During Attention Processing in Prolactinomas

Prolactinomas have been reported for the failure of cognitive functions. However, the electrophysiological mechanisms of attention processing in prolactinomas remain unclear. In a visual mission, we monitored the scalp electroencephalography (EEG) of the participants. Compared with the healthy controls (HCs), larger frontoparietal theta and alpha coherence were found in the patients, especially in the right-lateralized hemisphere, which indicated a deficit in attention processing. Moreover, the frontoparietal coherence was positively correlated with altered prolactin (PRL) levels, implying the significance of PRL for adaptive brain compensation in prolactinomas. Taken together, this research showed the variations in attention processing between the HCs and prolactinomas. The coherence between frontal and parietal regions may be one of the possible electrophysiological biomarkers for detecting deficient attention processing in prolactinomas.

In Vivo Characterization of Cortical and White Matter Microstructural Pathology in Growth Hormone-Secreting Pituitary Adenoma

Background

The growth hormone (GH) and insulin-like-growth factor 1 (IGF-1) axis has long been recognized for its critical role in brain growth, development. This study was designed to investigate microstructural pathology in the cortex and white matter in growth hormone-secreting pituitary adenoma, which characterized by excessive secretion of GH and IGF-1.

Methods

29 patients with growth hormone-secreting pituitary adenoma (acromegaly) and 31 patients with non-functional pituitary adenoma as controls were recruited and assessed using neuropsychological test, surface-based morphometry, T1/T2-weighted myelin-sensitive magnetic resonance imaging, neurite orientation dispersion and density imaging, and diffusion tensor imaging.

Results

Compared to controls, we found 1) acromegaly had significantly increased cortical thickness throughout the bilateral cortex (pFDR < 0.05). 2) T1/T2-weighted ratio in the cortex were decreased in the bilateral occipital cortex and pre/postcentral central gyri but increased in the bilateral fusiform, insular, and superior temporal gyri in acromegaly (pFDR < 0.05). 3) T1/T2-weighted ratio were decreased in most bundles, and only a few areas showed increases in acromegaly (pFDR < 0.05). 4) Neurite density index (NDI) was significantly lower throughout the cortex and bundles in acromegaly (pTFCE < 0.05). 5) lower fractional anisotropy (FA) and higher mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) in extensive bundles in acromegaly (pTFCE < 0.05). 6) microstructural pathology in the cortex and white matter were associated with neuropsychological dysfunction in acromegaly.

Conclusions

Our findings suggested that long-term persistent and excess serum GH/IGF-1 levels alter the microstructure in the cortex and white matter in acromegaly, which may be responsible for neuropsychological dysfunction.

Chronic adult-onset of growth hormone/IGF-I hypersecretion improves cognitive functions and LTP and promotes neuronal differentiation in adult rats

AIM

Besides their metabolic and endocrine functions, the growth hormone (GH) and its mediated factor, the insulin-like growth factor I (IGF-I), have been implicated in different brain functions, including neurogenesis. Long-lasting elevated GH and IGF-I levels result in non-reversible somatic, endocrine and metabolic morbidities. However, the subcutaneous implantation of the GH-secreting (GH-S) GC cell line in rats leads to the controllable over-secretion of GH and elevated IGF-I levels, allowing the experimental study of their short-term effects on brain functions.

METHODS

Adult rats were implanted with GC cells and checked 10 weeks later, when a GH/IGF-I-secreting tumour was already formed.

RESULTS

Tumour-bearing rats acquired different operant conditioning tasks faster and better than controls and tumour-resected groups. They also presented better retentions of long-term memories in the passive avoidance test. Experimentally evoked long-term potentiation (LTP) in the hippocampus was also larger and longer lasting in the tumour bearing than in the other groups. Chronic adult-onset of GH/IGF-I hypersecretion caused an acceleration of early progenitors, facilitating a faster neural differentiation, maturation and integration in the dentate gyrus, and increased the complexity of dendritic arbours and spine density of granule neurons.

CONCLUSION

Thus, adult-onset hypersecretion of GH/IGF-I improves neurocognitive functions, long-term memories, experimental LTP and neural differentiation, migration and maturation.

Hormone levels are related to functional compensation in prolactinomas: A resting-state fMRI study

Prolactinomas are tumors of the pituitary gland, which overproduces prolactin leading to dramatic fluctuations of endogenous hormone levels throughout the body. While it is not fully understood how endogenous hormone disorders affect a patient's brain, it is well known that fluctuating hormone levels can have negative neuropsychological effects. Using resting-state functional magnetic resonance imaging (rs-fMRI), we investigated whole-brain functional connectivity (FC) and its relationship with hormone levels in prolactinomas. By performing seed-based FC analyses, we compared FC metrics between 33 prolactinoma patients and 31 healthy controls matched for age, sex, and hand dominance. We then carried out a partial correlation analysis to examine the relationship between FC metrics and hormone levels. Compared to healthy controls, prolactinoma patients showed significantly increased thalamocortical and cerebellar-cerebral FC. Endogenous hormone levels were also positively correlated with increased FC metrics, and these hormone-FC relationships exhibited sex differences in prolactinoma patients. Our study is the first to reveal altered FC patterns in prolactinomas and to quantify the hormone-FC relationships. These results indicate the importance of endogenous hormones on functional compensation of the brain in patients with prolactinomas.

The role of serum growth hormone and insulin-like growth factor-1 in adult humans brain morphology

Growth hormone (GH) and its anabolic mediator, insulin-like growth factor-1 (IGF-1), have a critical role in the central nervous system. However, their detailed roles in the adult human brain are not clear. In this study, structural MRIs of 48 patients with GH-secreting pituitary adenoma (GH-PA), 48 sex- and age-matched clinical Non-Functional pituitary adenoma patients (NonFun-PA) and healthy controls (HCs) were assessed using voxel-based morphometry (VBM) and region-based morphometry (RBM). Correlation analyses helped determine the relationships between serum hormone levels and brain structure. The whole-brain gray matter volume (GMV) and white matter volume (WMV) significantly increased at the expense of cerebrospinal fluid volume (CSFV) in GH-PA (Bonferroni corrected, p<0.01). The increase in GMV and reduction in CSFV were significantly correlated with serum GH/IGF-1 levels (p<0.05). VBM showed significant correlations of the GMV/WMV alteration pattern between GH-PA vs HCs and GH-PA vs NonFun-PA and widespread bilateral clusters of significantly increased GMV and WMV in GH-PA (pFDR<0.05). RBM showed obviously increased GMV/WMV in 54 of 68 brain regions (p<0.05) in GH-PA compared to HCs. Our results provide imaging evidence that serum GH/IGF-1 contributes to brain growth, which may be a potential treatment option for neurodegenerative disorders and brain injury in humans.

Executive functioning and quality of life in acromegaly

Introduction

Active acromegaly is a rare chronic endocrine disorder caused by excessive growth hormone (GH). Clinical studies suggest that cognitive performance is impaired in acromegaly – particularly executive function as well as short- and long-term memory. This study compared the quality of life (QoL) and executive functioning in acromegaly patients vs healthy controls.

Materials and methods

This was an observational case–control study on 38 subjects divided into 19 acromegaly patients and 19 matched controls. The groups were evaluated for QoL, attention, and executive function. All subjects completed Acromegaly Quality of Life Questionnaire (AcroQoL), Trail Making Test (parts A and B), Stroop, and phonemic fluency tests.

Results

Acromegaly patients had an AcroQoL global score that was significantly lower than controls. There were significant differences between the acromegaly group and the control group in terms of the physical effects (P=0.001) and appearance (P<0.001) but not for personal relationships (P=0.421). Acromegaly patients performed worse in the trail making test part B. They provided significantly fewer words than healthy subjects in phonemic fluency testing. Although patients performed generally worse than controls, no significant differences were noted in the trail making test part A, Stroop test, and the constrained phonemic fluency.

Conclusion

Acromegaly patients display worse executive functioning than healthy controls and have a decreased QoL.

Personality Traits and Physical Complaints in Patients With Acromegaly: A Cross Sectional Multi-Center Study With Analysis of Influencing Factors

Objective: Acromegalic patients display a distinct neuropsychological profile and suffer from chronic physical complaints. We aimed to investigate in more detail these aspects in acromegalic patients, dependent on influencing factors like disease activity, age, sex, chronic medication, surgery, pituitary radiation, pituitary insufficiency and comorbidities. Design: Cross sectional, multicentric. Methods: 129 patients (M/W 65/64, 58.3 ± 12.7 years, 53/76 with active/controlled disease). Acromegalic patients completed the following inventories: NEO-FFI, IIP-D, and the Giessen Complaints List (GBB-24), after written informed consent. Age, sex, IGF-1 concentrations, comorbidities, treatment modalities and pituitary insufficiency were documented. Results: Acromegalic patients or specific patient-subgroups were more agreeable, neurotic, exploitable/permissive, introverted/socially avoidant, non-assertive/insecure, nurturant and less open to experience, cold/denying, domineering, compared to normal values from the healthy population (controls). Multivariable analysis demonstrated that these overall results were due to the specific patient subgroups as patients on chronic medication, with arthrosis and pituitary insufficiency. Disease activity was only associated with the trait nurturant. Higher scores for introversion were associated with arthrosis. Lower domineering was independent of any disease- or treatment related variable or comorbidity. The GBB inventory showed overall higher scores in patients, with higher scores for exhaustion and general complaints being associated with pituitary insufficiency, coronary heart disease and history of malignancy in the multivariable analysis. Joint complaints were independent of any disease- or treatment- related variable. Conclusions: We define new aspects of a distinct neuropsychological profile in patients with acromegaly, which are largely independent of disease activity. Chronic physical complaints are more pronounced in patients than in controls, with exhaustion and general complaints showing no association with disease activity.

Evidence of dysexecutive syndrome in patients with acromegaly

PURPOSE

This study aimed to explore different aspects of executive function in patients with acromegaly and investigate the cause of dysexecutive syndrome in these patients.

METHODS

We conducted five typical executive function tests (Stroop test, verbal fluency [VF] test, Hayling Sentence Completion Test [HSCT], N-back test, and Sustained Attention to Response Task [SART]) on 42 acromegalic patients and 42 strictly matched healthy controls. Comparative analyses were conducted for five major executive function domains. The Dysexecutive Questionnaire (DEX) was used to assess patients' subjective feelings about their executive function. All patients underwent a magnetic resonance imaging (MRI) examination and a blood test to determine their pituitary hormone levels before the tests were performed.

RESULTS

The patients exhibited worse results on the Stroop test, VF test, HSCT and N-back test compared to the healthy control group. Moreover, part B of the HSCT and the N-back test performance were negatively correlated with IGF-1 concentrations, and the duration of the disease was significantly associated with the Stroop color task results.

CONCLUSIONS

Acromegalic patients were severely impaired in semantic inhibition, executive processing, working memory and executive inhibition, and they have realized a portion of these deficits. A high level of IGF-1, disease duration may contribute to the impairment of specific aspects of executive function.

Evaluation of depressive mood and cognitive functions in patients with acromegaly under somatostatin analogue therapy

AIMS

Acromegaly is caused by a pituitary adenoma that releases excess growth hormone (GH) and a concomitant increase in insulin-like growth factor 1 (IGF-1). Acromegaly results not only in phenotypic changes, but also in neurologic complications as peripheral neuropathy and cognitive dysfunction. This study aimed to compare depressive mood and cognitive function in patients with acromegaly and in healthy controls as well as to determine the factors underlying cognitive dysfunction in the acromegalic patients.

MATERIALS AND METHODS

This study included 42 patients with acromegaly that were receiving somatostatin analogue therapy and 44 healthy controls. Memory, attention, visuospatial function, inhibitory function, abstract thinking, verbal fluency, and depressive mood were measured in the patients and controls.

RESULTS

Patients with acromegaly had lower learning (p = 0.01), planning (p = 0.03), complex attention and inhibitory function (p = 0.04) scores than the controls. There was no significant difference in depressive mood between the patients and controls (p > 0.05). Gamma knife radiosurgery did not negatively affect cognitive function (p > 0.05).

CONCLUSION

The present findings show that acromegaly negatively affects learning, attention, and planning.

Predictors of Quality of Life in Acromegaly: No Consensus on Biochemical Parameters

BACKGROUND

Quality of life (QoL) in patients with acromegaly is reduced irrespective of disease state. The contributions of multifactorial determinants of QoL in several disease stages are presently not well known.

OBJECTIVE

To systematically review predictors of QoL in acromegalic patients.

METHODS

Main databases were systematically searched using predefined search terms for potentially relevant articles up to January 2017. Inclusion criteria included separate acromegaly cohort, non-hereditary acromegaly, QoL as study parameter with clearly described method of measurement and quantitative results, N ≥ 10 patients, article in English and adult patients only. Data extraction was performed by two independent reviewers; studies were included using the PRISMA flow diagram.

RESULTS

We identified 1,162 studies; 51 studies met the inclusion criteria: 31 cross-sectional observational studies [mean AcroQoL score 62.7 (range 46.6-87.0, n = 1,597)], 9 had a longitudinal component [mean baseline AcroQoL score 61.4 (range 54.3-69.0, n = 386)], and 15 were intervention studies [mean baseline AcroQoL score 58.6 (range 52.2-75.3, n = 521)]. Disease-activity reflected by biochemical control measures yielded mixed, and therefore inconclusive results with respect to their effect on QoL. Addition of pegvisomant to somatostatin analogs and start of lanreotide autogel resulted in improvement in QoL. Data from intervention studies on other treatment modalities were too limited to draw conclusions on the effects of these modalities on QoL. Interestingly, higher BMI and greater degree of depression showed consistently negative associations with QoL. Hypopituitarism was not significantly correlated with QoL in acromegaly.

CONCLUSION

At present, there is insufficient published data to support that biochemical control, or treatment of acromegaly in general, is associated with improved QoL. Studies with somatostatin receptor ligand treatment, i.e., particularly lanreotide autogel and pegvisomant have shown improved QoL, but consensus on the correlation with biochemical control is missing. Longitudinal studies investigating predictors in treatment-naive patients and their follow-up after therapeutic interventions are lacking but are urgently needed. Other factors, i.e., depression and obesity were identified from cross-sectional cohort studies as consistent factors associated with poor QoL. Perhaps treatment strategies of acromegaly patients should not only focus on normalizing biochemical markers but emphasize improvement of QoL by alternative interventions such as psychosocial or weight lowering interventions.

Pharmacological approaches to intervention in hypomyelinating and demyelinating white matter pathology

White matter disease afflicts both developing and mature central nervous systems. Both cell intrinsic and extrinsic dysregulation result in profound changes in cell survival, axonal metabolism and functional performance. Experimental models of developmental white matter (WM) injury and demyelination have not only delineated mechanisms of signaling and inflammation, but have also paved the way for the discovery of pharmacological approaches to intervention. These reagents have been shown to enhance protection of the mature oligodendrocyte cell, accelerate progenitor cell recruitment and/or differentiation, or attenuate pathological stimuli arising from the inflammatory response to injury. Here we highlight reports of studies in the CNS in which compounds, namely peptides, hormones, and small molecule agonists/antagonists, have been used in experimental animal models of demyelination and neonatal brain injury that affect aspects of excitotoxicity, oligodendrocyte development and survival, and progenitor cell function, and which have been demonstrated to attenuate damage and improve WM protection in experimental models of injury. The molecular targets of these agents include growth factor and neurotransmitter receptors, morphogens and their signaling components, nuclear receptors, as well as the processes of iron transport and actin binding. By surveying the current evidence in non-immune targets of both the immature and mature WM, we aim to better understand pharmacological approaches modulating endogenous oligodendroglia that show potential for success in the contexts of developmental and adult WM pathology. This article is part of the Special Issue entitled 'Oligodendrocytes in Health and Disease'.

General health status and intelligence scores of children of mothers with acromegaly do not differ from those of healthy mothers

PURPOSE

To determine the physical status and intelligence scores of children of acromegalic mothers and to compare them with those of children from mothers without acromegaly.

METHODS

Six women with acromegaly who became pregnant under follow-up between 2010 and 2014 and their 16 children (group A) were assessed and compared with 16 children of healthy women (group B) and 15 children of women with prolactinoma (group C). The physical examinations of children were performed by the department of pediatric endocrinology and intelligence quotient (IQ) testing was undertaken by adult and pediatric psychiatry departments, using appropriate scales for their ages.

RESULTS

Six of the 16 children (girls/boys: 7/9) were born after the diagnosis of acromegaly. Five of the 6 pregnancies occured when the patients were taking somatostatin analogs, none continued taking the drugs during pregnancy. The mean IQ of groups A, B, and C were 106.4 ± 12.5, 105.3 ± 12.5, and 103.2 ± 16.1 respectively (p > 0.05). The mean ages, birth percentiles, recent weight and height standard deviation scores were similar between groups (p > 0.05). Two siblings from group A and 1 child from group B were large for gestational age at birth. At recent follow-up, two children from group A were found tall for their age and one from group C was short for his age and was placed under the care of pediatric endocrinology clinic.

CONCLUSIONS

Pregnancies in acromegaly seems to be uneventful and the general health status and IQ scores of children from women with and without acromegaly were found similar.

Phosphodiesterase-5 Inhibitors: Action on the Signaling Pathways of Neuroinflammation, Neurodegeneration, and Cognition

Phosphodiesterase type 5 inhibitors (PDE5-Is) have recently emerged as a potential therapeutic strategy for neuroinflammatory, neurodegenerative, and memory loss diseases. Mechanistically, PDE5-Is produce an anti-inflammatory and neuroprotection effect by increasing expression of nitric oxide synthases and accumulation of cGMP and activating protein kinase G (PKG), the signaling pathway of which is thought to play an important role in the development of several neurodiseases, such as Alzheimer's disease (AD), Parkinson's disease (PD), and multiple sclerosis (MS). The aim of this paper was to review present knowledge of the signaling pathways that underlie the use of PDE5-Is in neuroinflammation, neurogenesis, learning, and memory.

Psychological profile and quality of life in patients with acromegaly in Greece. Is there any difference with other chronic diseases?

Several studies have shown that acromegaly is associated with increased psychological morbidity. However, it is not known whether this is attributed to acromegaly per se or to its chronicity as a debilitating disease affecting quality of life (QoL). The aim of this study was to assess psychological profile in acromegalics compared with those suffering from other serious chronic diseases and healthy controls. Secondary end points were QoL assessment and its association with mood disturbances. Comparative, cross-sectional study conducted in Northern Greece (2011-2012). The Greek versions of the Profile of Mood States (POMS) and AcroQoL questionnaires were used to assess psychological status and QoL, respectively. Forty acromegalics, 40 age- and sex-matched people with other chronic diseases and 80 healthy controls were included. No significant differences were identified between acromegalics and those suffering from other chronic diseases, regarding tension, anger, depression, confusion, fatigue and vigor. Compared with healthy controls, acromegalics suffered more from depression and anger, which remained significant after controlling for age, gender and marital status (p = 0.003 and p = 0.048, respectively). Negative predictors were female gender, macroadenomas and radiotherapy. AcroQoL scores were negatively associated with POMS subscales. Males had better QoL than females. Other than a negative association between AcroQoL-relationships subscale and disease duration, no association with other parameters was observed. Acromegaly has a negative impact on psychological status, which is worse than that of general population, but comparable to other chronic diseases. Mood disturbances are associated with impaired QoL, mainly in females and those with longer disease duration.

Neurocognitive function in acromegaly after surgical resection of GH-secreting adenoma versus naïve acromegaly

Patients with active untreated acromegaly show mild to moderate neurocognitive disorders that are associated to chronic exposure to growth hormone (GH) and insulin-like growth factor (IGF-I) hypersecretion. However, it is unknown whether these disorders improve after controlling GH/IGF-I hypersecretion. The aim of this study was to compare neurocognitive functions of patients who successfully underwent GH-secreting adenoma transsphenoidal surgery (cured patients) with patients with naive acromegaly. In addition, we wanted to determine the impact of different clinical and biochemical variables on neurocognitive status in patients with active disease and after long-term cure. A battery of six standardized neuropsychological tests assessed attention, memory and executive functioning. In addition, a quantitative electroencephalography with Low-Resolution Electromagnetic Tomography (LORETA) solution was performed to obtain information about the neurophysiological state of the patients. Neurocognitive data was compared to that of a healthy control group. Multiple linear regression analysis was also conducted using clinical and hormonal parameters to obtain a set of independent predictors of neurocognitive state before and after cure. Both groups of patients scored significantly poorer than the healthy controls on memory tests, especially those assessing visual and verbal recall. Patients with cured acromegaly did not obtain better cognitive measures than naïve patients. Furthermore memory deficits were associated with decreased beta activity in left medial temporal cortex in both groups of patients. Regression analysis showed longer duration of untreated acromegaly was associated with more severe neurocognitive complications, regardless of the diagnostic group, whereas GH levels at the time of assessment was related to neurocognitive outcome only in naïve patients. Longer duration of post-operative biochemical remission of acromegaly was associated with better neurocognitive state. Overall, this data suggests that the effects of chronic exposure to GH/IGF-I hypersecretion could have long-term effects on brain functions.

Herniation of cerebellar tonsils in acromegaly: prevalence, pathogenesis and clinical impact

Herniation of cerebellar tonsils (CTH) might occur in acromegaly patients and improve after acromegaly treatment. Our study investigated CTH prevalence in acromegaly, its relationship with clinical, laboratory and neuroimaging findings and its possible pathogenesis and clinical impact. 150 acromegaly patients (median-age 56 years, age-range 21-88, 83 females) underwent brain magnetic resonance imaging (MRI). Clinical data, laboratory and pituitary adenoma imaging findings were recorded. CTH, posterior cranial fossa area, tentorial angle, clivus, supraocciput and Twining's line length were measured in acromegaly patients and controls, who included MRI of 115 consecutive subjects with headache or transient neurological deficits (control group-1) and 24 symptomatic classic Chiari 1 malformation patients (control group-2). Acromegaly patients were interviewed for symptoms known to be related with CTH. 22/150 acromegaly patients (15 %) and 8/115 control group-1 subjects presented with CTH (p = 0.04). In acromegaly patients, CTH correlated positively with younger age and inversely with GH-receptor antagonist treatment. Control group-2 had a shorter clivus than CTH acromegaly patients (40.4 ± 3.2 mm vs 42.5 ± 3.3 mm, p < 0.05), while posterior fossa measures did not differ among acromegaly subgroups (with and without CTH) and control group-1. Headache and vision problems were more frequent in CTH acromegaly patients (p < 0.05); two acromegaly patients presented with imaging and neurological signs of syringomyelia. Despite no signs of posterior fossa underdevelopment or cranial constriction, CTH is more frequent in acromegaly patients and seems to contribute to some disabling neurological symptoms.

Cognitive function in acromegaly: description and brain volumetric correlates

In acromegaly, we reported on increased rates of affective disorders such as dysthymia and depression, as well as structural brain changes. Objective of this study was to determine if cognitive impairments in patients with acromegaly exist and whether such impairments are associated with structural brain alterations defined by magnetic resonance imaging (MRI). In this cross-sectional study, 55 patients with biochemically confirmed acromegaly were enrolled. MRI data were compared with 87 control subjects. Main outcome measures were performance levels in 13 cognitive tests covering the domains of attention, memory and executive function, with performance below the cut-off level of the 16th percentile rated as impaired. In addition, individual global and hippocampal volume changes were defined for each patient in reference to a normative sample. We found that up to 33.3% of the patients were impaired in the attention, up to 24.1% in the memory, and up to 16.7% in the executive function domain. 67.3% of the patients failed to reach the cut-off level in at least one subtest. MRI demonstrated increased global, left and right hippocampal grey matter and white matter, particularly early in the disease course. Rather few positive than expected negative correlations could be established between the hippocampal grey matter gain and cognitive performance. Cognitive dysfunction, particularly attentional deficits, are common in acromegaly, rendering neuropsychological testing essential in the diagnostic work-up.

Prevalence of mental disorders in acromegaly: a cross-sectional study in 81 acromegalic patients

OBJECTIVE

Emotional and behavioural alterations have been described in acromegalic patients. However, the nature and psychopathological value of these changes remained unclear. We examined whether acromegalic patients have an increased prevalence of comorbid DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Version) mental disorders in comparison to subjects with or without chronic somatic disorders.

DESIGN/PATIENTS

A cross-sectional study was conducted at the Max-Planck Institute of Psychiatry and the Ludwig-Maximilians-University Munich. Eighty-one acromegalic patients were enrolled. Control subjects with (n = 3281) and without chronic somatic (n = 430) disorders were drawn from a representative sample of the German adult general population as part of the Mental Health Supplement of the German Health Interview and Examination Survey. Lifetime and 12-month prevalences of DSM-IV mental disorders were assessed with face-to-face interviews using the standardized German computer-assisted version of the Composite International Diagnostic Interview.

RESULTS

Acromegalic patients had increased lifetime rates of affective disorders of 34.6% compared to 21.4% in the group with chronic somatic disorders (OR = 2.0, 95% CI 1.2-3.2) and to 11.1% in the group without chronic somatic disorders (OR = 4.4, 95% CI 2.3-8.7). Affective disorders that occurred significantly more often than in the control groups began during the putative period of already present GH excess. Higher rates of DSM-IV mental disorders were reported in those patients with additional treatment after surgery.

CONCLUSION

Acromegaly is associated with an increased prevalence and a specific pattern of affective disorders. Greater emphasis on diagnosing and treatment of mental disorders in acromegalic patients might improve the disease management.