Acromegaly: clinical features at diagnosis

Pituitary Disorders

In this article, we will review common pituitary disorders. There are 6 hormones secreted by the anterior pituitary gland: thyroid-stimulating hormone, adrenocorticotropic hormone, follicle-stimulating hormone, luteinizing hormone, growth hormone, and prolactin. The posterior pituitary gland stores and releases the hormones made in the hypothalamus, oxytocin and antidiuretic hormone, based on the body's needs. This article will discuss the role of these hormones, conditions and symptoms that occur with elevated or reduced hormone levels, as well as the evaluation and treatment of these pituitary disorders.

Unlocking the Genetic Secrets of Acromegaly: Exploring the Role of Genetics in a Rare Disorder

Acromegaly is a rare endocrine disorder characterized by the excessive production of growth hormone (GH) in adulthood. Currently, it is understood that certain pituitary neuroendocrine tumors (PitNETs) exhibit a hereditary predisposition. These tumors' genetic patterns fall into two categories: isolated and syndromic tumors. The isolated forms are characterized by molecular defects that predispose exclusively to PitNETs, including familial isolated pituitary adenomas (FIPAs) and sporadic genetic defects not characterized by hereditary predisposition. All the categories involve either germline or somatic mutations, or both, each associated with varying levels of penetrance and different phenotypes. This highlights the importance of genetic testing and the need for a more comprehensive view of the whole disease. Despite the availability of multiple treatment options, diagnosis often occurs after several years, and management is still difficult. Early detection and intervention are crucial for preventing complications and enhancing the quality of life for affected individuals. This review aims to elucidate the molecular, clinical, and histological characteristics of GH-secreting PitNETs, providing insights into their prevalence, treatment nuances, and the benefits of genetic testing for each type of genetic disorder associated with acromegaly.

Clinical factors associated with salivary flow rate in adults with acromegaly

OBJECTIVE

To investigate the stimulated salivary flow (SSF) and unstimulated salivary flow (USF) in adults with acromegaly and to identify possible clinical factors associated with salivary flow.

STUDY DESIGN

A case-control study was conducted with a group composed of adults diagnosed with acromegaly (n = 29, mean age = 50.2 years) and a control group (n = 29, mean age = 54.3 years). Variables for socio-demographic characterization, lifestyle habits, and diabetes diagnosis, body mass index (BMI), cervical circumference (CC) and abdominal circumference (AC) were collected. USF and SSF variables were analyzed as outcomes. Unpaired t-test, Pearson's correlation, and multivariate regression models were used for statistical analysis.

RESULTS

Both groups were 44.8% male and 55.2% female. Diabetes was present in 55.2% of the acromegaly group and in 51.7% of the controls (P = .792). The acromegaly group had a higher USF than the control group (0.50 mL/min versus 0.22 mL/min). SSF showed a direct correlation with CC (r = 0.470, P = .010). Acromegaly was associated with higher USF (standardized coefficient = 0.780, P = .039), and age was inversely related to USF (standardized coefficient = -0.333, P = .013).

CONCLUSIONS

The findings suggest that adults with acromegaly have an increased USF and that being older is associated with a decrease in USF.

Three-Dimensional Speckle-Tracking Echocardiography-Derived Tricuspid Annular Properties in Acromegaly-Results from the MAGYAR-Path Study

INTRODUCTION

Acromegaly is an endocrine pathology characterized by the overproduction of human growth hormone. The present study aimed to analyze three-dimensional speckle-tracking echocardiography (3DSTE)-derived tricuspid annular (TA) properties in detail in patients with acromegaly and to compare the findings to those of matched healthy controls.

METHODS

The present study consisted of 29 patients with acromegaly (mean age: 55.9 ± 14.5 years, 21 males), of which 13 had an active disease. The control population comprised 57 healthy subjects (mean age: 53.2 ± 8.4 years, 38 males).

RESULTS

In the presence of acromegaly, left atrial and end-diastolic left ventricular (LV) sizes were dilated, and LV ejection fraction was increased, which was accompanied by thickened interventricular septum and LV posterior wall as compared with matched healthy controls. The presence of grade 1 mitral (MR) and tricuspid (TR) regurgitations were more frequent in acromegaly than in controls, regardless of disease activity. Higher than grade 1 MR/TR was uncommon in acromegaly. The 3DSTE-derived all end-diastolic (2.47 ± 0.27 cm vs. 2.23 ± 0.27 cm; 8.73 ± 1.77 cm2 vs. 6.67 ± 1.40 cm2; 11.56 ± 1.34 cm vs. 10.20 ± 1.10 cm, p < 0.001 for all) and end-systolic (1.97 ± 0.27 cm vs. 1.77 ± 0.28 cm; 6.24 ± 1.61 cm2 vs. 5.01 ± 1.42 cm2; 9.80 ± 1.35 cm vs. 8.72 ± 1.10 cm, p < 0.001 for all) TA diameters, areas, and perimeters proved to be dilated, while TA functional parameters including TA fractional area change (28.77 ± 9.80% vs. 27.64 ± 15.34%, p = 0.720) and fractional shortening (20.60 ± 9.08% vs. 20.51 ± 8.81%, p = 0.822) were normal in acromegaly regardless of whether acromegaly was active or not. RA volumes respecting the cardiac cycle were dilated in acromegaly as compared with those of healthy controls regardless of disease activity and were associated with respective changes in TA dimensions.

CONCLUSIONS

In the presented acromegaly patients, significant TA dilation with preserved function could be detected regardless of disease activity. RA volumes and TA dimensions are correlated in acromegaly.

Disrupted harmony of the skull skeleton: Middle ear resonance in acromegaly

OBJECTIVES

This study aims to investigate whether the middle ear resonance frequency (RF) is affected in acromegaly, which causes growth in the skull bone.

METHODS

Thirty acromegaly patients and 38 volunteers were included in the study. Pure tone average scores and middle ear RF values of the groups that underwent pure tone audiometry, tympanometry, and multifrequency tympanometry tests were compared.

RESULTS

The pure tone mean was 14.95 ± 12.13 in acromegaly patients and 5.70 ± 8.52 in the control group (p:0.18). Sensorineural hearing loss(SNHL) was observed in 16.6% of the patients. The average middle ear RF was calculated as 815 ± 179.05 Hz in patients with acromegaly and 773 ± 127.15 in the control group. (p = 0.0001).

CONCLUSION

This study is the first to evaluate middle-ear RF in acromegaly patients. Acromegaly-induced changes in soft tissues and bone structures impact middle ear functions. In this patient group, we found an increase in middle ear RF without conductive-type hearing loss and a 16.6% rate of SNHL.

The potential link between acromegaly and risk of acute ischemic stroke in patients with pituitary adenoma: a new perspective

Acromegaly is an endocrine disorder due to the excess production of growth hormone (GH) from the anterior pituitary gland after closed epiphyseal growth plates. Acromegaly is mainly caused by benign GH-secreting pituitary adenoma. Acute ischemic stroke (AIS) is one of the most common cardiovascular complications. It ranks second after ischemic heart disease (IHD) as a cause of disability and death in high-income countries globally. Thus, this review aimed to elucidate the possible link between acromegaly and the development of AIS. The local effects of acromegaly in the development of AIS are related to the development of pituitary adenoma and associated surgical and radiotherapies. Pituitary adenoma triggers the development of AIS through different mechanisms, particularly aneurysmal formation, associated thrombosis, and alteration of cerebral microcirculation. Cardiovascular complications and mortality were higher in patients with pituitary adenoma. The systemic effect of acromegaly-induced cardio-metabolic disorders may increase the risk for the development of AIS. Additionally, acromegaly contributes to the development of endothelial dysfunction (ED), inflammatory and oxidative stress, and induction of thrombosis that increases the risk for the development of AIS. Moreover, activated signaling pathways, including activator of transcription 3 (STAT3), nuclear factor kappa B (NF-κB), nod-like receptor pyrin 3 (NLRP3) inflammasome, and mitogen-activated protein kinase (MAPK) in acromegaly may induce systemic inflammation with the development of cardiovascular complications mainly AIS. Taken together, acromegaly triggers the development of AIS through local and systemic effects by inducing the formation of a cerebral vessel aneurysm, the release of pro-inflammatory cytokines, the development of oxidative stress, ED, and thrombosis correspondingly.

Addressing Acromegaly-Related Malocclusion With Surgery-First Orthognathic Surgery: A Clinical Case Report

Angle's class III malocclusions are characterized by the anterior positioning of the mandible in relation to the maxilla. The discrepancy can be caused by an anterior deficiency of the maxilla, excessive mandibular prognathism, or a combination of both. Acromegaly is a dysfunction caused by the excessive production of growth hormone (GH), which leads to systemic changes and orofacial manifestations. In acromegaly caused by a pituitary adenoma, which secretes an excessive amount of GH, disproportionate mandibular growth may occur, leading to skeletal class III malocclusion in adulthood. Excessive growth stops when the tumor is removed, but the skeletal deformity persists, requiring orthognathic surgery to reposition the mandible. This article reports the case of a 31-year-old man referred to the maxillofacial surgery consultation due to severe Angle's class III malocclusion, with prognathism, mandibular asymmetry, and maxillary retrusion. He had a history of disproportionate soft tissue growth (hands and feet) up to 18 years old, less evident after that age. Considering the possibility of acromegaly due to a pituitary adenoma, imaging studies (CT scan and magnetic resonance imaging (MRI)) and directed analytical studies were requested. When the diagnosis was confirmed, the patient was referred to endocrinology and neurosurgery consultations. After undergoing endoscopic resection of the pituitary adenoma, the patient underwent surgery-first orthognathic surgery to correct the dental malocclusion.

"Micromegaly": Acromegaly with apparently normal GH, an entity on its own?

A small proportion of the patients with acromegaly present with apparently normal basal GH levels and suppressible GH levels despite increased IGF-1 levels, a pattern called micromegaly by some authors. Whether this pattern represents a distinct entity or is just an expression of acromegaly in its early stages is still a matter of debate. Nevertheless, these patients have some peculiar characteristics such as being more likely older and male, mostly harbour microadenomas or small macroadenomas, and have lower IGF-1 and postglucose GH levels. Even though, the frequency and severity of clinical signs and comorbidities are similar to those of patients with classic acromegaly. In conclusion, micromegaly seems to be a distinct clinical entity with a different biological behavior characterized by a low GH output.

Surgical and non-surgical interventions for primary and salvage treatment of growth hormone-secreting pituitary adenomas in adults

BACKGROUND

Growth hormone (GH)-secreting pituitary adenoma is a severe endocrine disease. Surgery is the currently recommended primary therapy for patients with GH-secreting tumours. However, non-surgical therapy (pharmacological therapy and radiation therapy) may be performed as primary therapy or may improve surgical outcomes.

OBJECTIVES

To assess the effects of surgical and non-surgical interventions for primary and salvage treatment of GH-secreting pituitary adenomas in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, WHO ICTRP, and ClinicalTrials.gov. The date of the last search of all databases was 1 August 2022. We did not apply any language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of more than 12 weeks' duration, reporting on surgical, pharmacological, radiation, and combination interventions for GH-secreting pituitary adenomas in any healthcare setting.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance, screened for inclusion, completed data extraction, and performed a risk of bias assessment. We assessed studies for overall certainty of the evidence using GRADE. We estimated treatment effects using random-effects meta-analysis. We expressed results as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) for continuous outcomes, or in descriptive format when meta-analysis was not possible.

MAIN RESULTS

We included eight RCTs that evaluated 445 adults with GH-secreting pituitary adenomas. Four studies reported that they included participants with macroadenomas, one study included a small number of participants with microadenomas. The remaining studies did not specify tumour subtypes. Studies evaluated surgical therapy alone, pharmacological therapy alone, or combination surgical and pharmacological therapy. Methodological quality varied, with many studies providing insufficient information to compare treatment strategies or accurately judge the risk of bias. We identified two main comparisons, surgery alone versus pharmacological therapy alone, and surgery alone versus pharmacological therapy and surgery combined. Surgical therapy alone versus pharmacological therapy alone Three studies with a total of 164 randomised participants investigated this comparison. Only one study narratively described hyperglycaemia as a disease-related complication. All three studies reported adverse events, yet only one study reported numbers separately for the intervention arms; none of the 11 participants were observed to develop gallbladder stones or sludge on ultrasonography following surgery, while five of 11 participants experienced any biliary problems following pharmacological therapy (RR 0.09, 95% CI 0.01 to 1.47; 1 study, 22 participants; very low-certainty evidence). Health-related quality of life was reported to improve similarly in both intervention arms during follow-up. Surgery alone compared to pharmacological therapy alone may slightly increase the biochemical remission rate from 12 weeks to one year after intervention, but the evidence is very uncertain; 36/78 participants in the surgery-alone group versus 15/66 in the pharmacological therapy group showed biochemical remission. The need for additional surgery or non-surgical therapy for recurrent or persistent disease was described for single study arms only. Surgical therapy alone versus preoperative pharmacological therapy and surgery Five studies with a total of 281 randomised participants provided data for this comparison. Preoperative pharmacological therapy and surgery may have little to no effect on the disease-related complication of a difficult intubation (requiring postponement of surgery) compared to surgery alone, but the evidence is very uncertain (RR 2.00, 95% CI 0.19 to 21.34; 1 study, 98 participants; very low-certainty evidence). Surgery alone may have little to no effect on (transient and persistent) adverse events when compared to preoperative pharmacological therapy and surgery, but again, the evidence is very uncertain (RR 1.23, 95% CI 0.75 to 2.03; 5 studies, 267 participants; very low-certainty evidence). Concerning biochemical remission, surgery alone compared to preoperative pharmacological therapy and surgery may not increase remission rates up until 16 weeks after surgery; 23 of 134 participants in the surgery-alone group versus 51 of 133 in the preoperative pharmacological therapy and surgery group showed biochemical remission. Furthermore, the very low-certainty evidence did not suggest benefit or detriment of preoperative pharmacological therapy and surgery compared to surgery alone for the outcomes 'requiring additional surgery' (RR 0.48, 95% CI 0.05 to 5.06; 1 study, 61 participants; very low-certainty evidence) or 'non-surgical therapy for recurrent or persistent disease' (RR 1.22, 95% CI 0.65 to 2.28; 2 studies, 100 participants; very low-certainty evidence). None of the included studies measured health-related quality of life. None of the eight included studies measured disease recurrence or socioeconomic effects. While three of the eight studies reported no deaths to have occurred, one study mentioned that overall, two participants had died within five years of the start of the study.

AUTHORS' CONCLUSIONS

Within the context of GH-secreting pituitary adenomas, patient-relevant outcomes, such as disease-related complications, adverse events and disease recurrence were not, or only sparsely, reported. When reported, we found that surgery may have little or no effect on the outcomes compared to the comparator treatment. The current evidence is limited by the small number of included studies, as well as the unclear risk of bias in most studies. The high uncertainty of evidence significantly limits the applicability of our findings to clinical practice. Detailed reporting on the burden of recurrent disease is an important knowledge gap to be evaluated in future research studies. It is also crucial that future studies in this area are designed to report on outcomes by tumour subtype (that is, macroadenomas versus microadenomas) so that future subgroup analyses can be conducted. More rigorous and larger studies, powered to address these research questions, are required to assess the merits of neoadjuvant pharmacological therapy or first-line pharmacotherapy.

Analysis of Diffusion-Weighted and T2-Weighted Imaging in the Prediction of Distinct Granulation Patterns of Somatotroph Adenomas

OBJECTIVE

The heterogeneity of the somatotroph adenomas, especially for sparsely granulated (SG) and densely granulated (DG) subtypes, has attracted great attention in identifying their imaging biomarker. The purpose of the current study was to compare the diagnostic performance of diffusion-weighted and T2-weighted magnetic resonance imaging (MRI) sequences for preoperatively distinguishing the granulation patterns of somatotroph adenomas.

METHODS

Thirty-two patients with a clinical diagnosis of somatotroph adenomas from October 2018 to March 2023 were included in this study. Coronal diffusion-weighted imaging (DWI) and T2-weighted MRI sequence data were collected from 3.0T MRI and compared between SG and DG groups. The immunohistochemistry was used to confirm the electron microscopy pathologic subtypes and Ki67 expression levels of somatotroph adenomas postoperatively.

RESULTS

Patients in the SG group had significantly higher signal intensity (SI) ratio of DWI (rDWI) (P < 0.001), lower SI ratio of apparent diffusion coefficient (rADC) (P < 0.001), and higher SI ratio of T2-weighted imaging (P = 0.011). The combined diagnosis index of rDWI and rADC had the highest diagnostic efficiency in predicting SG adenomas (sensitivity, 93.3%; specificity, 88.2%; P < 0.001). The rDWI and rADC values had positive and negative correlations with the Ki67 index and tumor maximum diameter, respectively. Lower rADC×103 was an independent predictor for SG adenomas.

CONCLUSIONS

Our results indicated that compared with previously used T2-weighted imaging, the DWI sequence, especially the combined diagnosis index of rDWI and rADC, could more efficiently distinguish the granulation patterns of somatotroph adenomas preoperatively.

Position statement on the diagnosis and management of acromegaly: The French National Diagnosis and Treatment Protocol (NDTP)

Acromegaly is a rare disease with prevalence of approximately 60 cases per million, slight female predominance and peak onset in adults in the fourth decade. Clinical diagnosis is often delayed by several years due to the slowly progressive onset of symptoms. There are multiple clinical criteria that define acromegaly: dysmorphic syndrome of insidious onset, symptoms related to the pituitary tumor (headaches, visual disorders), general signs (sweating, carpal tunnel syndrome, joint pain, etc.), complications of the disease (musculoskeletal, cardiovascular, pneumological, dental, metabolic comorbidities, thyroid nodules, colonic polyps, etc.) or sometimes clinical signs of associated prolactin hypersecretion (erectile dysfunction in men or cycle disorder in women) or concomitant mass-induced hypopituitarism (fatigue and other symptoms related to pituitary hormone deficiencies). Biological confirmation is based initially on elevated IGF-I and lack of GH suppression on oral glucose tolerance test or an elevated mean GH on repeated measurements. In confirmed cases, imaging by pituitary MRI identifies the causal tumor, to best determine management. In a minority of cases, acromegaly can be linked to a genetic predisposition, especially when it occurs at a young age or in a familial context. The first-line treatment is most often surgical removal of the somatotroph pituitary tumor, either immediately or after transient medical treatment. Medical treatments are most often proposed in patients not controlled by surgical removal. Conformal or stereotactic radiotherapy may be discussed on a case-by-case basis, especially in case of drug inefficacy or poor tolerance. Acromegaly should be managed by a multidisciplinary team, preferably within an expert center such as a reference or skill center for rare pituitary diseases.

Pituitary adenomas registry in Thailand

PURPOSE

Pituitary adenomas are the most common sellar tumors, and may cause adverse outcomes in terms of morbidity and mortality if left untreated or if diagnosis is delayed. No data exists on the prevalence, characteristics, and prognosis of pituitary adenomas in Thailand. The systematic registration of clinical characteristics may improve patient care and prognosis for this disease in Thailand.

METHODS

This was a retrospective study conducted in 11 academic referral centers. All patients diagnosed with pituitary adenomas during the 2011---2014 period were enrolled in the study. The information was correlated with two national databases.

RESULTS

A total of 1,283 pituitary adenoma patients were identified. The adenomas were: non-functioning 50.1%, prolactinoma 29.4%, acromegaly 14.7%, Cushing disease 3.8%, gonadotropin-producing tumor 1.0%, TSH-secreting tumor 0.6%. The mean age was 49.2±15.2 years. Sixty-three percent of patients were female. Most common complaint was visual impairment (27.7%). The average size of the tumor was 22.2±16.1 mm. Fifty-nine percent of patients underwent surgery. Median follow-up was 27.4 months (0-24 years). After treatment, 72.4% improved, and 10.4% were cured. Overall results of treatment in non-functioning adenoma, prolactinoma (medically treated), acromegaly, Cushing, TSH, gonadotropin producing adenoma were: improved/cured in 81/5.5, 86/5.7, 55.9/30, 54.2/31.2, 85.7/14.3, 69.2/15.4% respectively.

CONCLUSION

Pituitary adenomas in academic centers in Thailand were found predominantly in female in the 4th decade of life. After treatment 72.4% of patients improved and 10% had full recovery. A health promotion system aimed to improve patient and physician recognition and physician expertise may improve the prognosis of these diseases.

Acromegaly: Pathophysiological Considerations and Treatment Options Including the Evolving Role of Oral Somatostatin Analogs

Acromegaly is a condition most commonly diagnosed in the fifth decade of life and has numerous treatment options. In this regard, Mycapssa® is the first FDA-approved oral octreotide capsule for treating acromegaly, combining the efficacy of the somatostatin receptor ligand, octreotide, with the ease of a twice-daily oral capsule. Where surgical treatment is not an option, somatostatin analogs, including octreotide, are the first line of medical treatment for acromegaly, requiring regular subcutaneous or intramuscular injections administered by a patient's healthcare provider. Octreotide capsules (Mycapssa®) provide an alternative to these somatostatin receptor ligand injections by combining octreotide with other excipients to produce a transient permeability enhancer technology that improves paracellular transport of octreotide across the gastrointestinal wall into the small intestine. Across multiple trials, including open-label (CH-ACM-01), double-blind placebo-controlled (CHIASMA OPTIMAL), and open-label extension of the trial period (CHIASMA OPTIMAL OLE), Mycapssa® octreotide capsules maintained a consistent biochemical normalization of IGF-1 and GH levels, safety profiles similar to injected somatostatin receptor ligands, and patient preference to continued treatment with octreotide capsules. While clinical trial data supports the use of octreotide capsules (Mycapssa®) in the pharmacological management of GH and IGF-1 levels, very little data exist regarding the drug's efficacy, tolerability, and use in female or pediatric-specific populations. A better understanding of the efficacy, application, and role of oral octreotide capsules in the long-term medical management of acromegaly in a diversity of populations is imperative to best determine the risks/benefits for the clinician.

Growth hormone proteoformics atlas created to promote predictive, preventive, and personalized approach in overall management of pituitary neuroendocrine tumors

Human growth hormone (GH) is the indispensable hormone for the maintenance of normal physiological functions of the human body, including the growth, development, metabolism, and even immunoregulation. The GH is synthesized, secreted, and stored by somatotroph cells in adenohypophysis. Abnormal GH is associated with various GH-related diseases, such as acromegaly, dwarfism, diabetes, and cancer. Currently, some studies found there are dozens or even hundreds of GH proteoforms in tissue and serum as well as a series of GH-binding protein (GHBP) proteoforms and GH receptor (GHR) proteoforms were also identified. The structure-function relationship of protein hormone proteoforms is significantly important to reveal their overall physiological and pathophysiological mechanisms. We propose the use of proteoformics to study the relationship between every GH proteoform and different physiological/pathophysiological states to clarify the pathogenic mechanism of GH-related disease such as pituitary neuroendocrine tumor and conduct precise molecular classification to promote predictive preventive personalized medicine (PPPM / 3P medicine). This article reviews GH proteoformics in GH-related disease such as pituitary neuroendocrine tumor, which has the potential role to provide novel insight into pathogenic mechanism, discover novel therapeutic targets, identify effective GH proteoform biomarker for patient stratification, predictive diagnosis, and prognostic assessment, improve therapy method, and further accelerate the development of 3P medicine.

Crosstalk between the mTOR and Hippo pathways

Cell behavior changes in response to multiple stimuli, such as growth factors, nutrients, and cell density. The mechanistic target of the rapamycin (mTOR) pathway is activated by growth factors and nutrient stimuli to regulate cell growth and autophagy, whereas the Hippo pathway has negative effects on cell proliferation and tissue growth in response to cell density, DNA damage, and hormonal signals. These two signaling pathways must be precisely regulated and integrated for proper cell behavior. This integrative mechanism is not completely understood; nevertheless, recent studies have suggested that components of the mTOR and Hippo pathways interact with each other. Herein, as per contemporary knowledge, we review the molecular mechanisms of the interaction between the mTOR and Hippo pathways in mammals and Drosophila. Moreover, we discuss the advantage of this interaction in terms of tissue growth and nutrient consumption.

Leukocyte Telomere Length and Neuregulin-4 Levels in Female Patients with Acromegaly: The Relationship between Disease Activity and Body Fat Distribution

The study aimed to examine leukocyte telomere length (LTL) and serum neuregulin-4 levels and their relationship with disease activity, co-morbidities and body fat distribution in female acromegaly patients. Forty female patients with acromegaly and thirty-nine age and body mass index (BMI) similar healthy female volunteers were included in the study. Patients were classified into two groups: active acromegaly (AA) and controlled acromegaly (CA). The quantitative polymerase chain reaction (PCR) method was used to study LTL, and T/S ratio < 1 was accepted as shortened telomere length. Neuregulin-4 was studied by ELISA. There was no difference in median LTL between acromegaly and the control group (p = 0.530). The percentage of T/S < 1 in patients with acromegaly (60.0%) was similar to that of the control group (43.6%) (p = 0.144). However, serum neuregulin-4 was significantly higher in patients with acromegaly than those in the control group (p = 0.037). There were no significant differences concerning LTL, percentage of T/S < 1 and neuregulin-4 levels between active and controlled acromegaly groups (p > 0.05). Neuregulin-4 correlated positively with fasting glucose, triglyceride (TG), triglyceride/glucose (TyG) index, and lean body mass in the acromegaly group. A negative correlation was observed between LTL and neuregulin-4 in the control group (p = 0.039). When the factors affecting neuregulin-4 were evaluated by multivariate linear regression analysis with an enter method, TG (β: 0.316, p = 0.025) was independently and positively associated with neuregulin-4. Our findings indicate that acromegaly is associated with unchanged LTL and high neuregulin-4 levels in female patients. However, the relationship between acromegaly, the aging process, and neuregulin-4 involves complex mechanisms, and further studies are needed.

Caloric restriction as a possible pitfall for persistent acromegaly follow-up - case report

BACKGROUND

Acromegaly diagnosis is established when plasma levels of IGF-1 are increased and the Oral Glucose Tolerance Test (OGTT) with 75gr of glucose can't suppress Growth Hormone (GH) levels. These two parameters are also useful during follow-up, after surgical/radiologic therapy and/or during medical therapy.

CASE PRESENTATION

A 29-year-old woman was diagnosed with acromegaly after a severe headache. Previous amenorrhea and facial and acral changes were noticed. A pituitary macroadenoma was found, biochemical evaluation was in agreement with the suspected acromegaly and a transsphenoidal adenectomy was performed. As the disease recurred, a surgical reintervention and radiosurgery (Gamma Knife, 22 Gy) were necessary. No normalization of IGF-1 was achieved during three years after radiosurgery. Surprisingly, then, and although clinical features seemed getting worse, IGF-1 levels became consistently controlled to 0.3-0.8 times the upper limit of the reference range. Questioned, the patient referred that she was following an intermittent fasting dietary plan. However, based on the dietary questionnaire, she was found to be under severe caloric restriction. First OGTT (under caloric restriction) showed absence of GH suppression and an IGF-1 value of 234 ng/dL (Reference Range 76-286 ng/mL). A second OGTT, one month after an eucaloric diet was instituted, showed an increased IGF-1 of 294 ng/dL, maintaining an unsuppressed, yet less elevated, GH.

CONCLUSIONS

GHRH/GH/IGF-1 axis controls somatic growth. Regulation is complex, and nutrition status and feeding pattern have a recognized role. Like systemic inflammation or chronic liver disease, fasting and malnutrition decrease the expression of hepatic GH receptors, with consequent reduction of IGF-1 levels, through resistance to GH. This clinical report shows that caloric restriction may represent a pitfall in acromegaly follow-up.

Giant growth hormone-secreting pituitary adenomas from the endocrinologist's perspective

OBJECTIVES

Since giant (≥40 mm) GH-secreting pituitary adenomas are rarely encountered, data on their characteristics and treatment outcomes are limited. We aimed to investigate the characteristics of giant GH-secreting pituitary adenomas and to compare their clinical, biochemical, imaging and histopathological features with non-giant macroadenomas.

MATERIALS AND METHODS

We have evaluated 15 (six female/nine male) and 57 (29 female/28 male) patients with acromegaly in giant and <40 mm adenoma groups, respectively. Patients with <40 mm adenoma were further divided into subgroups with adenoma size 20-29 mm and 30-39 mm.

RESULTS

In giant adenoma group, median (IQR) preoperative maximal diameter of adenoma was 40 mm (5 mm), median preoperative GH level was 40 (153.4) ng/mL and median baseline IGF-1 level was 2.19 (1.88) × ULN for age and sex. The number of surgeries was significantly higher in giant adenoma group (median 2, IQR 2) in which 66.7% of patients underwent repeated surgeries (p = 0.014). Residual tumor was detected after last operation in all patients with giant adenoma. Total number of treatment modalities administered postoperatively increased as adenoma size increased (p = 0.043). After a median follow-up duration of 10 years (IQR 10), hormonal remission was achieved in six patients (40%) of giant adenoma group, while the rate of hormonal remission in non-giant adenoma group was 37%. Although preoperative GH and IGF-1 levels and Ki-67 index tended to be higher with increasing adenoma size, there was no statistically significant difference between groups in terms of these variables, as well as age, sex and invasion status.

CONCLUSION

Hormonal remission rates of acromegaly patients with ≥20 mm pituitary macroadenoma were comparable. However, giant GH-secreting pituitary adenomas require an aggressive multimodal treatment approach.

The potential utility of the SAGIT instrument in the clinical assessment of patients with acromegaly, a large single-centre study

SAGIT is an instrument created for the clinical assessment of acromegaly. Our objective was to test the usefulness of this tool in assessing disease activity of acromegalic patients in a single centre of Poznan, Poland using a retrospective study. Medical records of patients with acromegaly hospitalised at the Department of Endocrinology, Metabolism and Internal Medicine of Poznan University of Medical Sciences in Poland between January 2015 and December 2020 were analysed. SAGIT scores were assessed according to each patient's clinical and biochemical data. The results show that SAGIT scores were higher in treatment-naïve patients and the lowest in controlled patients. There were positive correlations between SAGIT scores and concentrations of calcium, phosphorus, HbA1C levels, and tumour invasiveness at the time of diagnosis. However, parameters such as age, vitamin D concentration, and time from diagnosis showed an inverse relationship with the SAGIT score. In ROC curve analysis, SAGIT scores of 5 or less discriminated controlled patients from uncontrolled (p < 0.0001, sensitivity 76.7%, specificity 78.5%, AUC 0.867). Also, SAGIT higher than 6 indicated for treatment start or escalation (p < 0.0001, sensitivity 80.88%, specificity 77.59%, AUC 0.866). Lack of signs and symptoms (S = 0) could not discriminate between controlled and uncontrolled disease, but predicted therapy maintenance (p < 0.0004, sensitivity 59.5%, specificity 58.2%, AUC 0.604). In conclusion, The SAGIT instrument is easy to use even when completed in the retrospective medical record review. It can be useful for distinguishing clinical stages of acromegaly and in decision-making.

Prospect of acromegaly therapy: molecular mechanism of clinical drugs octreotide and paltusotine

Somatostatin receptor 2 (SSTR2) is highly expressed in neuroendocrine tumors and represents as a therapeutic target. Several peptide analogs mimicking the endogenous ligand somatostatin are available for clinical use, but poor therapeutic effects occur in a subset of patients, which may be correlated with subtype selectivity or cell surface expression. Here, we clarify the signal bias profiles of the first-generation peptide drug octreotide and a new-generation small molecule paltusotine by evaluating their pharmacological characteristics. We then perform cryo-electron microscopy analysis of SSTR2-Gi complexes to determine how the drugs activate SSTR2 in a selective manner. In this work, we decipher the mechanism of ligand recognition, subtype selectivity and signal bias property of SSTR2 sensing octreotide and paltusotine, which may aid in designing therapeutic drugs with specific pharmacological profiles against neuroendocrine tumors.

Polycystic ovary syndrome preceding the diagnosis of acromegaly: a retrospective study in 97 reproductive-aged women

BACKGROUND

Acromegaly is a disease of growth hormone excess that results in enlargement of extremities, abnormal glucose and lipid metabolism, and gonadal disruption. Manifestations of the disease are insidious and typically lead to a diagnostic delay of 7-10 years. Classically the polycystic ovary syndrome (PCOS) phenotype is described in women with irregular menses, clinical or biochemical evidence of androgen excess, and/or multiple ovarian follicles on pelvic ultrasonography. Women with acromegaly may present with some or all of these symptoms. Our objective was to evaluate the prevalence of PCOS in patients with acromegaly and to determine if diagnosis of PCOS results in a delay in diagnosing acromegaly.

METHODS

Using patient databases at two academic health centers, we identified 97 premenopausal women aged 18-49 years old presenting with acromegaly. Data were collected regarding pelvic sonography and reproductive history, including the diagnosis of PCOS. Patients carrying the diagnosis of PCOS before their diagnosis of acromegaly were identified and the remaining patients were screened using the Rotterdam criteria to identify additional patients meeting the criteria for PCOS prior to their diagnosis of acromegaly.

RESULTS

Mean age of the population (n = 97) at the time of diagnosis of acromegaly was 33.4 ± 7.5 years (SD). Thirty-three percent of patients (n = 32) either carried a diagnosis of PCOS or met diagnostic criteria for PCOS before their diagnosis of acromegaly. In the subset of patients in whom data on symptom onset were available, those who met criteria for PCOS were diagnosed with acromegaly a median of 5 years [4, 9] after the onset of symptoms compared to 2 years [0.92, 3] (p =  0.006) in the patients who did not meet criteria for PCOS.

CONCLUSIONS

Our data demonstrate a high prevalence of signs and symptoms of PCOS in reproductive-aged women with acromegaly and a longer time to diagnosis in women who meet the clinical criteria for PCOS. As screening for acromegaly is relatively simple and done with measurement of a random, non-fasting IGF-1 level that can be drawn at any time during the menstrual cycle, screening patients with PCOS for acromegaly may lessen the delay in diagnosis for reproductive-aged women with this disease.

PRESTO 2: An International Survey to Evaluate Patients' Injection Experiences with the Latest Devices/Formulations of Long-Acting Somatostatin Analog Therapies for Neuroendocrine Tumors or Acromegaly

INTRODUCTION

Real-world data evaluating patients' injection experiences using the latest devices/formulations of the long-acting (LA) somatostatin analogs (SSAs) lanreotide Autogel/Depot (LAN; Somatuline®) and octreotide LA release (OCT; Sandostatin®) are limited.

METHODS

PRESTO 2 was a 2020/2021 e-survey comparing injection experience of adults with neuroendocrine tumors (NETs) or acromegaly treated with LAN prefilled syringe versus OCT syringe for > 3 months in Canada, Ireland, the UK and the USA (planned sample size, 304).

PRIMARY ENDPOINT

the proportion of patients with injection-site pain lasting > 2 days after their most recent injection, analyzed using a multivariate logistic regression model. Secondary endpoints included interference with daily life due to injection-site pain and technical injection problems in patients with current SSA use for ≥ 6 months.

RESULTS

There were 304 respondents (acromegaly, n = 85; NETs, n = 219; LAN, n = 168; OCT, n = 136; 69.2% female; mean age, 59.6 years). Fewer patients had injection-site pain lasting > 2 days after the most recent injection with LAN (6.0%) than OCT (22.8%); the odds of pain lasting > 2 days were significantly lower for LAN than OCT, adjusted for disease subgroup and occurrence of injection-site reactions (odds ratio [95% confidence interval]: 0.13 [0.06-0.30]; p < 0.0001). Injection-site pain interfered with daily life "a little bit" or "quite a bit" in 37.2% and 3.8% (LAN) versus 52.5% and 7.5% (OCT) of patients, respectively. Among patients with ≥ 6 months' experience with current SSA (92.4% of patients), technical injection problems never occurred in 76.8% (LAN) and 42.9% (OCT) of patients.

CONCLUSIONS

Compared with OCT, significantly fewer patients using LAN had injection-site pain lasting > 2 days after their most recent injection. Also, fewer LAN-treated patients experienced technical problems during injection. These findings demonstrate the importance of injection modality for overall LA SSA injection experience for patients with acromegaly or NETs.

Self-reported symptoms in patients with acromegaly: a 6-month follow-up in a single neurosurgical center

Acromegaly is characterized by hypersecretion of growth hormone (GH) and insulin-like growth factor 1 (IGF-1), accompanied by a compromise in the perception of wellness. The Patient-Assessed Acromegaly Symptom Questionnaire (PASQ) is relevant to assessing signs and symptoms but is mainly used to evaluate the efficacy of a pharmacological intervention. To explore the perioperative variation in symptom severity, the divergence between subgroups stratified according to clinical outcomes or treatment modalities, and the interaction between symptom scores and clinical indices, we prospectively recruited 106 patients with acromegaly from 2016 to 2018. Oral glucose tolerance and GH tests were performed, and PASQ was administered before treatment and 6 months postoperatively. Patients were divided into active (n = 49) and remission (n = 57) groups according to postoperative GH and IGF-1 levels. PASQ scores and GH and IGF-1 levels decreased significantly postoperatively in both groups. A significantly higher preoperative headache score and greater extent of decrease in arthralgia were seen in the active and remission groups, respectively. No significant variation in PASQ scores was found between patients receiving surgery alone and those receiving preoperative somatostatin analogs. Preoperative fasting GH (GH0) levels were positively correlated with preoperative excessive perspiration. Further regression analyses validated the variation in GH0 as a noteworthy determinant of the extent of change in soft-tissue swelling, excessive perspiration, fatigue, and total PASQ scores. Patient-reported symptoms were substantially alleviated after surgery, independent of endocrine remission or use of preoperative somatostatin. A GH level decrease was a notable coefficient for PASQ scores.

Growth hormone and gastrointestinal malignancy: An intriguing link

Growth hormone (GH) excess is associated with several systemic complications, one of which is the increased risk of neoplastic processes particularly of the gastrointestinal (GI) tract. Among the GI neoplasms, the most reported association is with benign and malignant neoplasms of the colon. In the majority of published literature, an increased incidence of GI neoplasms, both colonic adenomas as well as colorectal carcinoma is reported. However, the studies on colon cancer-specific mortality rate are conflicting with recent studies reporting similar cancer-specific mortality rates in comparison to controls. Many studies have reported an association of colorectal neoplasms with GH levels. Pathogenic mechanisms put forward to explain this association of GH excess and GI neoplasms primarily involve the increased GH-insulin-like growth factor 1 (IGF-1) signaling. Both GH and IGF-1 have proliferative, anti-apoptotic, and angiogenic effects on the systemic tissues leading to cellular proliferation. Other contributing factors to the increased risk of GI neoplasms include slow intestinal transit with a redundant large bowel, altered bile acids, deranged local immune response, shared genetic susceptibility factors and hyperinsulinemia. In view of the increased risk association, most guidelines for the care of acromegaly patients recommend an initial screening colonoscopy. Recommendations for further follow-up colonoscopy differ but broadly, the guidelines agree that it depends on the findings at first colonoscopy and state of remission of GH excess. Regarding the concern about the risk of colorectal cancers in patients receiving recombinant GH therapy, most cohort studies do not show an increased risk.

Real-time detection of acromegaly from facial images with artificial intelligence

OBJECTIVE

Despite improvements in diagnostic methods, acromegaly is still a late-diagnosed disease. In this study, it was aimed to automatically recognize acromegaly disease from facial images by using deep learning methods and to facilitate the detection of the disease.

DESIGN

Cross-sectional, single-centre study.

METHODS

The study included 77 acromegaly (52.56 ± 11.74, 34 males/43 females) patients and 71 healthy controls (48.47 ± 8.91, 39 males/32 females), considering gender and age compatibility. At the time of the photography, 56/77 (73%) of the acromegaly patients were in remission. Normalized images were obtained by scaling, aligning, and cropping video frames. Three architectures named ResNet50, DenseNet121, and InceptionV3 were used for the transfer learning-based convolutional neural network (CNN) model developed to classify face images as "Healthy" or "Acromegaly". Additionally, we trained and integrated these CNN machine learning methods to create an Ensemble Method (EM) for facial detection of acromegaly.

RESULTS

The positive predictive values obtained for acromegaly with the ResNet50, DenseNet121, InceptionV3, and EM were calculated as 0.958, 0.965, 0.962, and 0.997, respectively. The average sensitivity, specificity, precision, and correlation coefficient values calculated for each of the ResNet50, DenseNet121, and InceptionV3 models are quite close. On the other hand, EM outperformed these three CNN architectures and provided the best overall performance in terms of sensitivity, specificity, accuracy, and precision as 0.997, 0.997, 0.997, and 0.998, respectively.

CONCLUSIONS

The present study provided evidence that the proposed AcroEnsemble Model might detect acromegaly from facial images with high performance. This highlights that artificial intelligence programs are promising methods for detecting acromegaly in the future.

A Complete Form of Pachydermoperiostosis Accompanied by a Pituitary Microadenoma

Pachydermoperiostosis is a rare genetic disease that is associated with HPGD (15-hydroxyprostaglandin dehydrogenase) and SLCO2A1 (solute carrier organic anion transporter family member 2A1) gene mutations. It is characterized by three major phenotypes, namely, pachydermia, periostosis, and digital clubbing. Clinically, misdiagnoses such as acromegaly and thyroid acropachy are commonly confused with pachydermoperiostosis. Integral medical history, physical examination, endocrinological tests, and multiple disciplinary cooperation are extremely significant in the accurate diagnosis of pachydermoperiostosis. The co-existence of pachydermoperiostosis and pituitary adenoma is rarely recorded and discussed. In this case, we present a young male patient with a complete form of pachydermoperiostosis and a nonfunctional pituitary microadenoma, which has rarely been reported.

Effects of Anterior Pituitary Adenomas' Hormones on Glucose Metabolism and Its Clinical Implications

Pituitary adenomas have recently become more common and their incidence is increasing yearly. Functional pituitary tumors commonly secrete prolactin, growth hormones, and adrenocorticotropic hormones, which cause diseases such as prolactinoma, acromegaly, and Cushing's disease, but rarely secrete luteinizing, follicle-stimulating, thyroid-stimulating, and melanocyte-stimulating hormones. In addition to the typical clinical manifestations of functional pituitary tumors caused by excessive hormone levels, some pituitary tumors are also accompanied by abnormal glucose metabolism. The effects of these seven hormones on glucose metabolism are important for the treatment of diabetes secondary to pituitary tumors. This review focuses on the effects of hormones on glucose metabolism, providing important clues for the diagnosis and treatment of related diseases.

Case report: Clinical and single-cell transcriptome sequencing analysis of a mixed gangliocytoma-adenoma presenting as acromegaly

Background

Mixed gangliocytoma-adenoma (MGA) is a rare tumor of pituitary gland. It's difficult to distinguish it from pituitary adenoma by clinical manifestations, imaging features or serological testing. Thus, the histopathological examination is still the golden standard for diagnosis. Besides, studies on molecular level are still lacking.

Case information

In this case report, we described a 28-year-old male with MGA presenting as acromegaly, who suffered staging operation and post-operation gamma knife radiosurgery, but finally died of secondary hyperglycemic hyperosmolar collapse. A complete data including clinical, histopathological, ultrastructural and single-cell transcriptome level information were collected and analyzed.

Conclusion

This case report detailed the only clinical and molecular report of MGA following operation and radiotherapy. Complete clinical data enhanced the understanding of the diagnosis and treatment of this disease. Besides, the single-cell transcriptome sequencing analysis further disclosed the intra-tumoral heterogeneity and provided support for subsequent basic research.

Determinants of skeletal fragility in acromegaly: a systematic review and meta-analysis

PURPOSE

Vertebral fractures (VFs) are a potential complication in acromegaly. However, the etiology of this skeletal fragility is unknown. This review aimed to evaluate the effect of acromegaly on VFs, bone turnover, areal bone mineral density (aBMD), and bone quality/microarchitecture. The effect of disease activity and gonadal status in these determinants of skeletal fragility was also evaluated.

METHODS

Articles published in English until September 6, 2020 on PubMed and Embase that reported at least one determinant of skeletal fragility in acromegalic patients, were included. Odds ratio (OR) to evaluate the risk of VFs and the standardized mean difference (SMD) to evaluate bone turnover, aBMD and bone quality/microarchitecture were calculated.

RESULTS

Fifty-eight studies met eligibility criteria, assembling a total of 2412 acromegalic patients. Of these, 49 studies were included in the meta-analysis. Acromegalic patients, when compared to non-acromegalic patients, had higher risk of VFs [OR 7.00; 95% confidence interval (CI) 2.80-17.52; p < 0.0001], higher bone formation (SMD 1.14; 95% CI 0.69-1.59; p < 0.00001), higher bone resorption (SMD 0.60; 95% CI 0.09-1.10; p = 0.02) and higher aBMD at the femoral neck (SMD 0.36; 95% CI 0.15-0.57; p = 0.0009). No significant differences were found regarding aBMD at lumbar spine. Considering the results of the different techniques evaluating bone quality/microarchitecture, the main reported alterations were a decrease in trabecular bone thickness and density, and an increase in trabecular separation. The presence of active disease and/or hypogonadism were associated with worst results.

CONCLUSION

Patients with acromegaly are at increased risk of VFs, mainly because of deterioration in bone microarchitecture.

Cost-effectiveness of direct surgery versus preoperative octreotide therapy for growth-hormone secreting pituitary adenomas

PURPOSE

The objective of this study was to compare the cost-effectiveness of preoperative octreotide therapy followed by surgery versus the standard treatment modality for growth-hormone secreting pituitary adenomas, direct surgery (that is, surgery without preoperative treatment) from a public third-party payer perspective.

METHODS

We developed an individual-level state-transition microsimulation model to simulate costs and outcomes associated with preoperative octreotide therapy followed by surgery and direct surgery for patients with growth-hormone secreting pituitary adenomas. Transition probabilities, utilities, and costs were estimated from recent published data and discounted by 3% annually over a lifetime time horizon. Model outcomes included lifetime costs [2020 United States (US) Dollars], quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs).

RESULTS

Under base case assumptions, direct surgery was found to be the dominant strategy as it yielded lower costs and greater health effects (QALYs) compared to preoperative octreotide strategy in the second-order Monte Carlo microsimulation. The ICER was most sensitive to probability of remission following primary therapy and duration of preoperative octreotide therapy. Accounting for joint parameter uncertainty, direct surgery had a higher probability of demonstrating a cost-effective profile compared to preoperative octreotide treatment at 77% compared to 23%, respectively.

CONCLUSIONS

Using standard benchmarks for cost-effectiveness in the US ($100,000/QALY), preoperative octreotide therapy followed by surgery may not be cost-effective compared to direct surgery for patients with growth-hormone secreting pituitary adenomas but the result is highly sensitive to initial treatment failure and duration of preoperative treatment.

Risk of Neurodegenerative Diseases in Patients With Acromegaly: A Cohort Study

BACKGROUND AND OBJECTIVES

A few recent studies have reported an association between insulin-like growth factor-1 (IGF-1) and neurodegenerative disease, but there was no report on any association between acromegaly and neurodegenerative disease. We investigated whether the risk of Alzheimer disease (AD), Parkinson disease, and other neurodegenerative diseases was increased among patients with acromegaly using nationwide data of Korea.

METHODS

We studied the association between acromegaly and Parkinson disease and dementia in 1,611 patients with acromegaly and controls (age-matched and sex-matched 8,055 participants with no diagnosis of acromegaly) from the National Health Insurance System database between 2006 and 2016 with a mean follow-up period of 7.34 years. Cox proportional hazards regression analysis was used to assess the risk of all outcomes in patients with acromegaly compared with controls with adjusting for age, sex, household income, place, type 2 diabetes, hypertension, and dyslipidemia.

RESULTS

The average age of the patients with acromegaly and the controls was 54.16 years (40.4% men). The incidence rate of Parkinson disease in patients with acromegaly (1.54 per 1,000 person-years) was significantly higher than that in the control group (0.55 per 1,000 person-years) (log-rank test p = 0.001). Acromegaly was associated with a higher risk of Parkinson disease (hazard ratio [HR] = 2.609, 95% CI: 1.410-2.609) than the control. In addition, acromegaly was associated with a higher risk of all-cause dementia (HR = 2.299, 95% CI: 1.362-3.881), Alzheimer disease (HR = 2.228, 95% CI: 1.191-4.168), and non-AD dementia (HR = 6.553, 95% CI: 1.754-24.482) than the control during the first 3 years after diagnosis and treatment. In subgroup analysis, diabetes was associated with higher risk of all-cause dementia (P for interaction = 0.028) in patients with acromegaly compared with controls.

DISCUSSION

Our study results suggest that acromegaly is associated with neurodegenerative disease. Further study is needed on the association between IGF-1/growth hormone level and neurodegenerative disease.

Incidence of ossification of the spinal ligaments in acromegaly patients

Some previous case reports have implied a relationship between acromegaly and ossification of the spinal ligaments. However, there have been no reports of a case series exploring the incidence of ossification of the spinal ligaments in patients with acromegaly. To this end, computed tomography (CT) of the spine in 10 consecutive patients with acromegaly was examined in this study. Five out of 10 patients had ossification of the spinal ligaments. Among them, two patients had ossification of the posterior longitudinal ligament (OPLL), which was noticeably higher than the prevalence of OPLL in the general adult population (1.9–4.3 %). Body mass index was significantly higher in the group with spinal ligament ossification (p = 0.03), but there were no significant differences in age, sex, serum phosphate, albumin-adjusted calcium, growth hormone (GH), standard deviation of insulin-like growth factor-1 (IGF-1), or the incidence of diabetes mellitus between the groups with or without ossification of the spinal ligaments. The ossification index (OS index) was used to determine the severity of spinal ligament ossification, and there were no significant correlations between the OS index and GH or IGF-1 (p = 0.51 and 0.75, respectively). This study was the first to report a high prevalence of spinal ossification in patients with acromegaly. In conclusion, this study suggested a possible association between acromegaly and ossification of the spinal ligaments, although the number of patients was insufficient to draw a conclusion. Acromegaly patients should be tested to confirm, or rule out, spinal ossification, and further studies to clarify the underlying mechanism of spinal ossification in acromegaly patients are warranted.

The Role of Psychologists in Sport Medicine Practice

Young athletes face a unique set of stressors from nonathletes that require careful screening and management. Internalizing disorders, substance use, overtraining, eating disorders, the female athlete triad, and sport-related injury are some psychological issues related to sports participation. Young athletes experiencing these conditions may experience functional impairment and distress on and off the field and management of these concerns includes routine screening and intervention. Embedding a psychologist within a pediatric sports medicine clinic improves patients' access to psychological screenings, early identification, and early intervention for these concerns athletes face.

A study on serum pro-neurotensin (PNT), furin, and zinc alpha-2-glycoprotein (ZAG) levels in patients with acromegaly

PURPOSE

Acromegaly caused by growth hormone cell adenoma is commonly associated with abnormal glucolipid metabolism, which may result from changes in adipocytokine secretion. This study aims to investigate serum adipokine levels, including pro-neurotensin (PNT), furin, and zinc alpha-2-glycoprotein (ZAG), in acromegalic patients and the correlation between the levels of these three adipokines and GH levels and glucolipid metabolism indices.

METHODS

Sixty-eight acromegalic patients and 121 controls were included, and their clinical data were recorded from electronic medical record system. Serum PNT, furin and ZAG levels were measured by ELISA.

RESULTS

Serum PNT levels in acromegalic patients were significantly higher than controls (66.60 ± 12.36 vs. 46.68 ± 20.54 pg/ml, P < 0.001), and acromegaly was an independent influencing factor of PNT levels (P < 0.001). Moreover, subjects with the highest tertile of PNT levels had a close correlation with acromegaly (OR = 22.200, 95% CI 7.156 ~ 68.875, P < 0.001), even in Model 1 adjusted for gender and age and Model 2 adjusted for gender, age and BMI. Additionally, serum PNT levels were positively correlated with BMI (r = 0.220, P = 0.002) and triglycerides (TGs, r = 0.295, P < 0.001), and TGs were an independent influencing factor of serum PNT levels in acromegalic subjects (P < 0.001). Furthermore, serum PNT levels in obese acromegalic patients were significantly higher than those with normal BMI (P < 0.05). However, serum furin levels were lower in acromegalic patients than controls (0.184 ± 0.036 vs. 0.204 ± 0.061 ng/ml, P < 0.001).

CONCLUSION

This study is the first to demonstrate that acromegalic patients have increased serum PNT levels. Moreover, serum PNT plays a potential role in abnormal lipid metabolism of acromegalic patients.

Acromegaly-related cutis verticis gyrata

OBJECTIVE

Acromegaly is a disorder caused by hypersecretion of growth hormone (GH), resulting in excessive levels of insulin-like growth factor 1 (IGF-1), and almost always due to a pituitary tumor. It is classically associated with acral enlargement, prominent facial features and soft tissue overgrowth. Skin manifestations include hirsutism, acne, skin tags, oily skin and acanthosis nigricans. However, other uncommon dermatological features, such as cutis verticis gyrata (CVG), may also occur. Here, we review acromegaly-related CVG aiming to raise awareness for its possible occurrence in this setting, and we discuss its pathophysiology, presentation, management and differential diagnosis.

DESIGN

A comprehensive literature search regarding CVG, particularly CVG related to acromegaly, has been carried out. Case reports, original studies and review papers, were considered.

RESULTS

CVG is a rare benign skin lesion characterized by thickened and folded scalp, resembling the brain gyri and sulci. The diagnosis of CVG mainly relies on clinical examination, although tissue biopsy may be necessary in case of uncertain etiology. In acromegaly, CVG appears to be driven by the trophic effects of GH and IGF-1 on skin and soft tissues. While CVG is uncommon in acromegaly, it seems to occur more frequently in male patients. The management of acromegaly-related CVG essentially relies on controlling the serum levels of GH and IGF-1. Surgical skin procedures should be reserved for patients with severe aesthetic distress, after achieving the best possible control of acromegaly.

CONCLUSIONS

CVG is a rare manifestation of acromegaly that may allow an earlier diagnosis and a swifter treatment of these patients, which in turn may improve or entirely reverse such remarkable skin lesions.

A Comprehensive Review of Four Clinical Practice Guidelines of Acromegaly

Acromegaly is an endocrine disorder characterized by dysregulated hypersecretion of growth hormone (GH), leading to an overproduction of insulin-like growth factor 1 (IGF-1). The etiology is usually a GH-secreting pituitary adenoma with the resultant presentation of coarse facial features, frontal bossing, arthritis, prognathism (protrusion of the mandible), and impaired glucose tolerance, among others. Most pituitary adenomas arise due to sporadic mutations that lead to unregulated cellular division, subsequent tumor formation, and resultant GH hypersecretion. Major scientific organizations and authorities in endocrinology release regularly updated guidelines for diagnosing and managing acromegaly. We have holistically evaluated four data-driven and evidentiary approaches in the management of acromegaly to compare and contrast these guidelines and show their salient differences. These guidelines have been reviewed because they are major authorities in acromegaly management. In this comprehensive article, differences in the diagnosis and treatment recommendations of the discussed guidelines have been highlighted. Our findings showed that diagnosing modalities were similar among the four approaches; however, some guidelines were more specific about additional supporting investigations to confirm a diagnosis of acromegaly.

For management options, each guideline had suggestions about ideal therapeutic outcomes. Treatment options were identical but salient differences were noticed, such as the addition of combination therapy and alternative therapy in the setting of failure to respond to first and second-line treatments. Reviewing clinical guidelines for various pathologies encourages sharing ideas among medical practitioners and ensures that global best practices are adopted. Therefore, a constant review of these clinical practice guidelines is necessary to keep clinicians up to date with the latest trends in patient management.

Pituitary apoplexy after COVID-19 vaccination: A case report

Background

Pituitary apoplexy is a rare endocrine emergency, which commonly presents with headache and is occasionally associated with visual disturbances. Prompt diagnosis and treatment can be both life and vision saving. In the emergence of novel coronavirus and global pandemic, rapid development of new vaccines have shown to reduce morbidity and mortality associated with Covid-19. Recognition of rare potential adverse effects of these vaccines including pituitary apoplexy are yet to be reported. A causal link between pituitary apoplexy and COVID-19 vaccination has not been established.

Case presentation

We report a case of a 24-year-old woman who presented with progressively worsening headache soon after completing her COVID-19 vaccination. Imaging showed pituitary apoplexy with an underlying pituitary mass. In view of the age and the typical presentation of severe headache, pituitary hypophysitis was considered, despite the absence of the almost pathognomonic feature of a thickened pituitary stalk in the initial imaging. In the context that the headache had started shortly after the administration of the second dose of COVID-19 vaccine, this potentially could have been the trigger for the occurrence of pituitary apoplexy.

Conclusion

Although the pathophysiology is not entirely clear and no direct link could be ascertained, our patient may have developed an exaggerated immunological response after the vaccine, with a possible pituitary hypophysitis leading to a pituitary apoplexy.

Patient-reported outcomes in patients with acromegaly treated with pegvisomant in the ACROSTUDY extension: A real-world experience

PURPOSE

To report the effects of pegvisomant (PEGV) treatment on patient-reported outcomes in acromegaly patients.

METHODS

We conducted an extension study of an open-label, multinational, non-interventional study (ACROSTUDY) evaluating the long-term safety and efficacy of PEGV for acromegaly in routine clinical practice. Enrolled patients were rollover patients from ACROSTUDY, or treatment naïve/semi-naïve (NSN; no PEGV within 6 months of enrollment). Exploratory efficacy endpoints were changes in symptoms with the Patient-Assessed Acromegaly Symptom Questionnaire (PASQ) and quality of life with the Acromegaly Quality of Life questionnaire (AcroQoL) analyzed by controlled or uncontrolled IGF-I levels. Results were analyzed in all patients, in NSN patient subgroup, and by diabetes status.

RESULTS

A total of 544 patients with acromegaly were enrolled, including 434 rollover subjects from ACROSTUDY and 110 NSN patients. Mean PEGV treatment duration was 7.8 years (range, 0-19.6 years). Overall, the majority of PASQ scores improved over time, but there was no significant difference between IGF-I controlled or uncontrolled groups. In the NSN subgroup, most PASQ and AcroQoL scores remained similar to baseline up to 1 year, regardless of IGF-I control. Patients with diabetes reported better PASQ scores over time with PEGV treatment, regardless of IGF-I control. IGF-I normalization increased from 10% of patients at baseline to more than 78% at year 10, with a mean daily PEGV dose of 18.7 mg.

CONCLUSIONS

Overall, patients treated with PEGV had small improvements in PASQ. While IGF-I normalization increased with PEGV treatment, IGF-I control had no effects on PASQ and AcroQoL scores.

Growth hormone modulates Trypanosoma cruzi infection in vitro

OBJECTIVE

Chagas disease (CD) is caused by the protozoan parasite, Trypanosoma cruzi. It affects 7 to 8 million people worldwide and leads to approximately 50,000 deaths per year. In vitro and in vivo studies had demonstrated that Trypanosoma cruziinfection causes an imbalance in the hypothalamic-pituitary-adrenal (HPA) axis that is accompanied by a progressive decrease in growth hormone (GH) and prolactin (PRL) production. In humans, inactivating mutations in the GH receptor gene cause Laron Syndrome (LS), an autosomal recessive disorder. Affected subjects are short, have increased adiposity, decreased insulin-like growth factor-I (IGFI), increased serum GH levels, are highly resistant to diabetes and cancer, and display slow cognitive decline. In addition, CD incidence in these individuals is diminished despite living in highly endemic areas. Consequently, we decided to investigate the in vitro effect of GH/IGF-I on T. cruzi infection.

DESIGN

We first treated the parasite and/or host cells with different peptide hormones including GH, IGFI, and PRL. Then, we treated cells using different combinations of GH/IGF-I attempting to mimic the GH/IGF-I serum levels observed in LS subjects.

RESULTS

We found that exogenous GH confers protection against T. cruzi infection. Moreover, this effect is mediated by GH and not IGFI. The combination of relatively high GH (50 ng/ml) and low IGF-I (20 ng/ml), mimicking the hormonal pattern seen in LS individuals, consistently decreased T. cruzi infection in vitro.

CONCLUSIONS

The combination of relatively high GH and low IGF-I serum levels in LS individuals may be an underlying condition providing partial protection against T. cruzi infection.

Stigma and unhealthy psychological characteristics in patients with acromegaly: A cross-sectional study and identification of the associated factors

BACKGROUND

Stigma, besides aggravating the damage caused by the disease, may also lead to unhealthy characteristics in patients and unhealthy situations in society. Individuals with acromegaly disease may suffer from stigma concerns, and the associated factors remain largely unknown. Therefore, the present cross-sectional study aimed to investigate the levels of perceived stigma in patients with acromegaly and explore the associated factors.

METHODS

A total of 138 patients with acromegaly were evaluated for having stigma using five previously validated scales: (i) the Stigma Scale for Chronic Illness, (ii) the Hamilton Anxiety Scale, (iii) the Rosenberg Self-Esteem Scale, (iv) the Body Image Concern scale, and (v) the Acromegaly Quality of Life scale. The potential determinants of stigma were evaluated using the univariate statistical analysis. A multivariate linear regression model was adopted to assess the predictors of stigma in patients with acromegaly. Pearson's correlation analysis was performed to analyze the relationship between stigma and the quality of life of the patients.

RESULTS

Among the 138 respondents, 102 provided consent for participation.The evaluated patients exhibited critically high levels of perceived stigma. The multiple regression analysis revealed high BMI, serious body image concerns, inferiority complex personality, and critical levels of anxiety as the potential predictors of stigma in patients with acromegaly. The overall stigma and internalized stigma were significantly correlated with QoL in these patients.

CONCLUSION

The patients with acromegaly exhibited critically high levels of perceived stigma, which led to psychological distress and disruptions in their daily lives. This finding highlights the importance of addressing the stigma concerns and the necessity for providing additional support to these patients in this regard during follow-up sessions. Further research should focus on developing intervention strategies to decrease the levels of perceived stigma in patients with acromegaly to promote their quality of life and for the psychosocial rehabilitation of these patients.

Physical Examination for Endocrine Diseases: Does It Still Play a Role?

A physical examination represents a fundamental step in diagnosing diseases. Due to the role that hormones play in the regulation of numerous biological processes in various organs and systems, endocrine diseases cause a variety of clinical manifestations that can be easily identified with a careful physical examination and can guide the clinician to specific diagnoses. Furthermore, the presence of specific clinical signs in various endocrine-metabolic diseases can predict the risk of developing comorbidities and serious adverse events. In this article, we present some of the main clinical signs of endocrine-metabolic diseases and the risk of comorbidities, summarizing the pathogenetic mechanisms that lead to their formation. The aim is to highlight how the identification of these specific signs can reduce the number of dynamic tests and the costs necessary to reach the diagnosis and allow the early identification of any complications associated with these diseases, improving the clinical management of affected patients.

The biochemical diagnosis of acromegaly: revising the role of measurement of IGF-I and GH after glucose load in 5 questions

INTRODUCTION

Acromegaly is a rare disorder characterized by the excessive secretion of growth hormone (GH), mostly caused by pituitary adenomas. While in full-blown cases the diagnosis is easy to establish, milder cases are more challenging. Additionally, establishing whether full cure after surgery is reached may be difficult.

AREAS COVERED

In this article, we will review the challenges posed by the variability in measurements of GH and its main effector insulin-like growth factor I (IGF-I) due to both biological changes, co-morbidities, and assays variability.

EXPERT OPINION

Interpretation of GH and IGF-I assays is important in establishing an early diagnosis of acromegaly, in avoiding misdiagnosis, and in establishing if cure is achieved by surgery. Physicians should be familiar with the variables that affect measurements of these 2 hormones, and with the performance of the assays available in their practice.

Non-Plaque Induced Diffuse Gingival Overgrowth: An Overview

Non-plaque induced diffuse gingival overgrowth represents a broad class of conditions caused by several etiological factors. The aim of this review is to highlight the most recent updates and classifications of all the existent gingival overgrowths. In addition, we highlighted the diagnostic pathway that should be employed in patients affected by gingival overgrowth. Gingival overgrowth can be related to syndromic diseases including a wide spectrum of genetic and chromosomal alterations. However, thanks to scientific sharing and the availability of genetic panels it is possible to obtain an accurate phenotypic identification of well-known syndromes and also to identify new ones. This narrative review shows that through rigid, strict diagnostic protocols, the work of the clinician is greatly facilitated, despite the wide variety of pathologies considered. In conclusion, the exchange of specialists’ competencies and the multidisciplinary management of these patients, are crucial to reach diagnosis and the correct clinical-therapeutic management.

Thymic hyperplasia due to excess growth hormone stimulation: A case report

Growth hormone has a strong role in stimulation of the thymus. We report a case of thymic hyperplasia due to excess endogenous growth hormone in the setting of acromegaly. Acromegaly often presents with systemic manifestations that may be confused with a systemic hematologic malignancy or infection, especially if an anterior mediastinal mass is present but unrecognized as a benign thymic hyperplasia. It is important for radiologists to be aware of this association between growth hormone and thymic stimulation because it may increase confidence diagnosing thymic hyperplasia in this setting, and avoid unnecessary mediastinal biopsy or surgery.

Low prevalence of neuropathic-like pain symptoms in long-term controlled acromegaly

PURPOSE

Pain is a common symptom of acromegaly, impairing health-related quality of life (HR-QoL) significantly despite long-term disease remission. Neuropathic-like pain (NP-like) symptoms are invalidating, with great impact on HR-QoL. Studies characterizing or investigating the etiology of pain in acromegaly are scarce. Therefore, we aimed to assess NP-like symptoms in a cohort of controlled acromegaly patients.

METHODS

Forty-four long-term controlled acromegaly patients (aged 62.6 ± 12.6 years; 56.8% female) were included in this cross-sectional study. NP-like symptoms were assessed using the validated painDETECT questionnaire. Patients were divided in three probability-based NP-like symptoms categories based on the total score (range 0-35): unlikely (≤ 12), indeterminate (13-18) and likely (≥ 19). HR-QoL (physical component score (PCS), and mental component score (MCS)), and self-reported pain were assessed using Short Form-36 (SF-36). Potential risk factors were determined using linear regression analyses.

RESULTS

Self-reported pain was reported by 35 patients (79.5%). Likely NP-like symptoms were present in 4/44 patients (9.1%), and indeterminate NP-like symptoms in 6/44 patients (13.6%). All patients with likely NP-like symptoms were female. Higher painDETECT scores were negatively associated with HR-QoL (PCS: r = - 0.46, P = 0.003; MCS: r = - 0.37, P = 0.018), and SF-36 pain scores (r = - 0.63, P < 0.0001). Female sex was a risk factor for NP-like symptoms.

CONCLUSIONS

Pain was prevalent in controlled acromegaly patients, whereas NP-like symptoms were relatively infrequent, and only observed in females. NP-like symptoms were associated with lower HR-QoL in acromegaly. Since specific analgesic therapy is available, awareness for characterization, increased understanding, and clinical trials regarding neuropathic pain identification and treatment in acromegaly patients are warranted.

Comparative Study of Malocclusions between Cancer Patients and Healthy Peers

Background. There is lack of data related to dental occlusion among children cured from cancer. The aim of our study was to compare the prevalence of malocclusion in cancer survivors and in healthy peers. Methods. A cross-sectional study was conducted on 225 children aged between 4 and 18 years, including 75 cancer survivors, and 150 sex and age-matched controls. All patients were orthodontically examined and malocclusion traits were recorded. In the cancer group, 75 panoramic radiographs were used to evaluate the prevalence of dental anomalies and dental age using the Demirjian scale. Data were analyzed by univariate statistical analysis with p-values p < 0.05 considered as statistically significant. Results. Malocclusion was found in 49 (65.33%) cancer survivors and 99 (65.56%) controls (p > 0.05). The cancer group demonstrated significantly higher likelihood of crossbite (p < 0.01) and malalignment of teeth (p = 0.031). The healthy controls were more likely to demonstrate open bite (p = 0.038). Cancer patients with posterior crossbite (p = 0.023) or dental malalignment had a more advanced dental age (p = 0.022). Survivors with crossbite had more teeth with short roots (p = 0.016). Those who were older when they started their cancer therapy were more likely to suffer from tooth disturbances (p = 0.019). Conclusion. Oncological treatment can alter the development of occlusion in cancer patients.

Extraocular Muscle Enlargement in Growth Hormone-Secreting Pituitary Adenomas

BACKGROUND AND PURPOSE

While Graves disease is the most common cause of extraocular muscle enlargement, case reports have also associated growth hormone-secretory pituitary adenomas with this same phenomenon. We investigated the prevalence and response to treatment of extraocular muscle enlargement in patients with growth hormone-secretory pituitary adenomas.

MATERIALS AND METHODS

We retrospectively reviewed extraocular muscle sizes using MR imaging in patients with growth hormone-secretory pituitary adenomas who underwent a transsphenoidal surgical resection compared with a matched control group with nonsecretory pituitary adenomas. Descriptive and comparative statistics were used to evaluate patient characteristics and extraocular muscle sizes between the 2 groups.

RESULTS

We identified 16 patients who presented with growth hormone-secreting pituitary adenomas and underwent transsphenoidal surgical resection from 2010 to 2019. The average diameter of the extraocular muscle at the time of diagnosis for the group with growth hormone-secretory pituitary adenomas was larger than that in the control group (4.7 versus 3.8 mm, P < .001). Nine patients achieved insulin-like growth factor 1 level normalization at a median of 11.5 months before their most recent MR imaging evaluation. The average size of the extraocular muscles of patients who achieved a normalized insulin-like growth factor 1 was smaller compared with those that did not (difference, 0.7 mm; 95% CI, 0.3-1.2 mm; P < .001), approaching the size of extraocular muscle in the control group.

CONCLUSIONS

We describe a high prevalence of extraocular muscle enlargement in patients with growth hormone-secreting pituitary adenomas. Additionally, we note that the size of extraocular muscles decreased with associated improvement in the biochemical control of acromegaly.

Dante Alighieri (1265-1321): an "infernal" endocrinological observation

The year 2021 marks the 700th anniversary of Dante's death. Is it appropriate to celebrate this anniversary in a journal of endocrinology? The answer is yes-the motivation for this being found in the giants that Dante, in his Divine Comedy, places around the well that divides Circle 8 from Circle 9 of Hell. The "Supreme Poet" describes one of the giants (Nimrod, a Biblical character) as having a large and elongated face with a body of gargantuan proportions. Such a description immediately calls to mind the characteristics of acromegalic prognathism, the huge stature being the most pathognomonic aspect. Is it possible that the sharp eye of Dante had observed such a feature in people affected by actual gigantism?

Oral Manifestations and Maxillo-Facial Features in the Acromegalic Patient: A Literature Review

Background: Acromegaly is a chronic disease caused by an abnormal secretion of growth hormone (GH) by a pituitary adenoma, resulting in an increased circulating concentration of insulin-like growth factor 1 (IGF-1). The main characteristics are a slow progression of signs and symptoms, with multisystemic involvement, leading to acral overgrowth, progressive somatic changes, and a complex range of comorbidities. Most of these comorbidities can be controlled with treatment. The literature reveals that the most evident and early signs are those related to soft tissue thickening and skeletal growth, especially in the head and neck region. Methods: The authors reviewed the available literature on the clinical oro-dental features of acromegaly, selecting articles from PubMed and Google Scholar. The aim of this review was to summarize all the reported clinical oro-dental features of acromegalic patients. Results: The most common facial dimorphisms involved the maxillo-facial district, with hypertrophy of the paranasal sinuses, thickening of the frontal bones, and protruding glabella, which may be associated with joint pain and clicks. Regarding the oro-dental signs, the most frequent are dental diastema (40–43%), mandibular overgrowth (22–24%), mandibular prognathism (20–22%), and macroglossia (54–58%). These signs of acromegaly can be significantly reduced with adequate treatment, which is more effective when initiated early. Conclusions: Increased awareness of acromegaly among dentists and maxillo-facial surgeons, along with the early identification of oro-facial changes, could lead to an earlier diagnosis and treatment, thereby improving patients’ quality of life and prognosis.

Real-world experience with pasireotide-LAR in resistant acromegaly: a single center 1-year observation

CONTEXT

Pasireotide-LAR, a second-generation somatostatin receptor ligand (SRL), is recommended for patients with acromegaly as second-line treatment. Its efficacy and safety were assessed in clinical trials; however, the real-world evidence is still scarce.

OBJECTIVE

The aim of this study was to evaluate the impact of 1-year treatment with pasireotide-LAR on disease control and glucose metabolism in acromegaly patients resistant to first-generation SRLs.

DESIGN

A single-center prospective study.

METHODS

Twenty-eight patients with active acromegaly or acrogigantism on first-generation SRLs following ineffective pituitary surgery were switched to treatment with pasireotide-LAR 40 or 60 mg i.m. every 28 days. To assess the efficacy of the treatment GH and IGF-1 levels were measured every 3 months. Safety of treatment was carefully evaluated, especially its impact on glucose metabolism.

RESULTS

Complete biochemical control (GH ≤ 1 ng/mL and IGF-1 ≤ 1 × ULN) was achieved in 26.9% of patients and partial + complete response (GH ≤ 2.5 ng/mL and IGF-1 ≤ 1.3 × ULN) in 50.0% of patients. Mean GH level decrease was the largest within first 6 months (P = 0.0001) and mean IGF-1 level decreased rapidly within the first 3 months (P < 0.0001) and they remained reduced during the study. Blood glucose and HbA1c levels increased significantly within 3 months (P = 0.0001) and stayed on stable level thereafter. Otherwise, the treatment was well tolerated and clinical improvement was noticed in majority of patients.

CONCLUSIONS

This real-life study confirmed good effectiveness of pasireotide-LAR in patients resistant to first-generation SRLs. Pasireotide-LAR was overall safe and well tolerated, however significant glucose metabolism worsening was noted.