Diagnosis, treatment and follow-up of patients with acromegaly in a clinical practice setting in Spain: the ACROPRAXIS program Delphi survey

Evaluation of the impact Of ChatGPT support on acromegaly management and patient education

PURPOSE

ChatGPT is a widely used artificial intelligence modeling tool. Healthcare is one potential area of use of ChatGPT. This study aimed to test the usability and reliability of ChatGPT in acromegaly, which is less known in society and should be evaluated by a group of specialized physicians.

METHODS

The study is designed in two parts. For the first part, 35 questions regarding acromegaly that patients frequently ask were identified, and these questions were asked to ChatGPT. In the second part, four patient examples were presented to ChatGPT using medical terminology. Three experts evaluated ChatGPT's answers to the questions and approaches in case management using 7-point scales in terms of safety, reliability, correctness, and usability.

RESULTS

When the ChatGPT answers to the patient's questions were evaluated, a mean score of 6.78 ± 0.55 was given for correctness and 6.69 ± 0.60 for reliability. The mean scores given by the raters for correctness, safety and usability in the evaluation of the cases were as follows: 6.33 ± 0.88, 6.16 ± 0. 71 and 6.08 ± 0.79 points for case 1; 5.35 ± 1.88, 5.29 ± 1.80 and 5.20 ± 1.86 points for case 2; 6.08 ± 0.97, 6.00 ± 0.93 and 5.91 ± 0.82 points for case 3; 6.10 ± 1.29, 6.13 ± 1.30 and 6.16 ± 1.14 points for case 4.

CONCLUSION

ChatGPT can actively answer the questions of acromegaly patients. Although it is not a reliable source alone in managing patients with acromegaly, it can be a supportive tool for physicians.

Acromegaly: diagnostic challenges and individualized treatment

INTRODUCTION

Acromegaly is due in almost all cases to a GH-secreting pituitary tumor. GH and IGF-1 excesses lead to its multi-system clinical manifestations and comorbidities. Acromegaly is under-diagnosed and typically presents with advanced disease. When early or mild, clinical recognition and biochemical confirmation are especially challenging. Individualized treatment may optimize patient outcome.

AREAS COVERED

This review covers challenges to diagnosing acromegaly and reviews therapies for acromegaly with a focus on those aspects that can be individualized.

EXPERT OPINION

The first step in diagnosing acromegaly is recognizing it clinically. To improve this, increase awareness and education of the general population and healthcare professionals about the acromegaly phenotype is needed. Once suspected clinically, IGF-1 measurement is the initial step in making the biochemical diagnosis. GH may be < 1.0 µg/L after oral glucose suppression in early/mild cases. GH and IGF-1 should be considered in concert. Providers should be aware of conditions that can alter GH and IGF-1 levels and each assay's performance. An individualized treatment approach is best employed. Surgery is preferred as initial treatment and medical therapy as initial adjuvant therapy. In individualizing therapy, the advantages and disadvantages of each option and predictors of response to them should be considered.

Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) in Patients With Acromegaly in Colombia

Background Acromegaly is a rare, chronic, and progressive disorder characterized by excessive secretion of growth hormone (GH) after the closure of the epiphyseal plates. The disease has an estimated annual incidence of 5 cases per 1,100,000 individuals. Sleep apnea/hypopnea syndrome (OSAHS) affects up to 80% of individuals with acromegaly and is recognized as an independent risk factor for the development of cardiovascular disease. This study aims to estimate the prevalence of SAHS and its associated factors in patients with acromegaly in Colombia. Methods This observational, retrospective cohort study utilized the National Registry of Patients with Acromegaly (RAPACO) data. The study evaluated patients who had undergone baseline polysomnography as a criterion for inclusion. Results A total of 163 patients were included in the study, of whom 89 (54.6%) were diagnosed with OSAHS. Women accounted for 99 (60.7%) of the cohort, aged 34.4 to 63.54 years. Patients with OSAHS exhibited a higher BMI and a longer disease duration. Additionally, they demonstrated elevated levels of IGF-1 (936.2 ± 447.2) and baseline GH (20.0 ± 20.4), both of which were statistically significant (p = 0.006 and p = 0.027, respectively). Severe apnea was the most prevalent form of the condition, and microadenoma was the predominant tumor type. Multivariate analysis identified disease duration and IGF-1 levels as the primary variables associated with OSAHS. Conclusion OSAHS is a prevalent comorbidity in patients with acromegaly, with hormonal factors playing a critical role in its pathogenesis. Consistent with previous studies, our findings demonstrate that elevated IGF-1 and GH levels are associated with greater OSAHS severity. Routine polysomnography (PSG) is recommended following the diagnosis of acromegaly. If OSAHS is confirmed, appropriate treatment should be initiated, and follow-up PSG should be performed during acromegaly management.

Acromegaly among a Moroccan population

Acromegaly is defined as an acquired dysmorphytic syndrome due to excessive secretion of growth hormone (GH) and consequently of insulin-like growth factor-1 (IGF-1). This is a retrospective study of patients who were hospitalized in the Endocrinology Department of the Mohammed V Military Academic Hospital in Rabat over a period of 14 years (2008 to 2022), reporting on their clinical, paraclinical and evolutionary profiles and comparing the results with the data in the literature. Nineteen patients were included in our study. The mean age was 42.7 ± 11.6 years, with a male predominance. The clinical manifestations were dominated by a dysmorphic syndrome present in 97.4% of cases, followed by complications related to acromegaly in 88.9% of cases. The diagnosis was made when GH and IGF-1 values were elevated in 88.9% and 93.8% of cases, respectively; with a mean GH value of 25.1 μg/L. Magnetic resonance imaging (MRI) was used to diagnose the location of pituitary adenoma in all cases, 78.9% of which were macroadenomas and 21.1% microadenomas. The majority of patients (78.9%) had recourse to transsphenoidal surgery. Medical treatment was carried out in 89.5% of cases. Postoperative radiotherapy was performed in 33% of cases. Disease control was achieved in 30.1% of cases. This study shows the complex management of acromegaly. Disease control is a necessary condition in order to avoid complications, but is often difficult to obtain.

Preference of acromegaly patients for treatment attributes in Spain

OBJECTIVE

Acromegaly is a rare disease caused by increased growth hormone secretion and a subsequent increase in insulin-like growth factor I (IGF-I) levels. Patients display multiple comorbidities that affect their quality of life (QoL). Treatment aims to maintain good biochemical control, tumour control and reduce the risk of comorbidities; however, their impact on QoL has been overlooked until recently. We interviewed patients to explore their preferences with regard to treatment attributes.

DESIGN

A cross-sectional study based on interviews and a discrete choice experiment (DCE) in a Spanish cohort.

METHODS

Adult patients diagnosed with acromegaly ≥1 year before the start of the study and under treatment were included. Treatment attributes were collected from patient testimony during face-to-face interviews. Then, a DCE was performed to elicit patient preferences for certain treatment attributes.

RESULTS

Sixty-seven patients completed the study. QoL improvement was the most important treatment attribute (37%), followed by IGF-I control (20%), blood sugar control (17%) and tumour control (13%). Secondary attributes were pain associated with the route of administration (7%), diarrhoea (2%), administration method (2%) and storage conditions (2%). We then calculated the theoretical share of preference for existing treatments, based on the individual preference utility for each attribute and level. Pegvisomant obtained the highest share of preference overall, and the highest preference as a second-line treatment (53 and 95%, respectively).

CONCLUSIONS

QoL greatly influences patient treatment preference. Since acromegaly patients are informed and aware of their disease, treatment choices should always be shared with patients.

A Delphi consensus on the management of anticoagulation in the COVID-19 pandemic: the MONACO study

Background

During the COVID-19 pandemic, guideline documents on the management of anticoagulation were rapidly published. However, these documents did not follow a structured methodology, and significant differences existed between the guidelines. The aim of this expert consensus was to provide recommendations on the clinical management of oral anticoagulation in patients in the context of the COVID-19 pandemic.

Methods

A two-round Delphi study was conducted using an online survey. In the first round, panellists expressed their level of agreement with the items on a 9-point Likert scale. Items were selected if they received approval from ≥66.6% of panellists and if they were agreed by the scientific committee. In the second round, panellists revaluated those items that did not meet consensus in the first round.

Results

A total of 147 panellists completed the first round, and 144 of them completed the second round. Consensus was reached on 161 items included in five dimensions. These dimensions addressed: (I) management of anticoagulation in patients with atrial fibrillation (AF) without mechanical valves or moderate/severe mitral stenosis during COVID-19 infection; (II) thromboprophylaxis in patients hospitalised for COVID-19; (III) management of anticoagulation at hospital discharge/after COVID-19; (IV) anticoagulation monitoring in the COVID-19 pandemic setting; and (V) role of telemedicine in the management and follow-up of patients with AF in the COVID-19 pandemic setting.

Conclusions

These areas of collective agreement could specially guide clinicians in making decisions regarding anticoagulation in patients with COVID-19 during hospitalisation and at discharge, where results from clinical trials are still limited and, in some cases, conflicting.

Predictors and dynamic online nomogram for postoperative delayed hyponatremia after endoscopic transsphenoidal surgery for pituitary adenomas: a single-center, retrospective, observational cohort study with external validation

BACKGROUND

Postoperative delayed hyponatremia (PDH) is a major cause of readmission after endoscopic transsphenoidal surgery (eTSS) for pituitary adenomas (PAs). However, the risk factors associated with PDH have not been well established, and the development of a dynamic online nomogram for predicting PDH is yet to be realized. We aimed to investigate the predictive factors for PDH and construct a dynamic online nomogram to aid in its prediction.

METHODS

We analyzed the data of 226 consecutive patients who underwent eTSS for PAs at the Department of Neurosurgery in Jinling Hospital between January 2018 and October 2020. An additional 97 external patients were included for external validation. PDH was defined as a serum sodium level below 137 mmol/L, occurring on the third postoperative day (POD) or later.

RESULTS

Hyponatremia on POD 1-2 (OR = 2.64, P = 0.033), prothrombin time (PT) (OR = 1.78, P = 0.008), and percentage of monocytes (OR = 1.22, P = 0.047) were identified as predictive factors for PDH via multivariable logistic regression analysis. Based on these predictors, a nomogram was constructed with great discrimination in internal validation (adjusted AUC: 0.613-0.688) and external validation (AUC: 0.594-0.617). Furthermore, the nomogram demonstrated good performance in calibration plot, Brier Score, and decision curve analysis. Subgroup analysis revealed robust predictive performance in patients with various clinical subtypes and mild to moderate PDH.

CONCLUSIONS

Preoperative PT and the percentage of monocytes were, for the first time, identified as predictive factors for PDH. The dynamic nomogram proved to be a valuable tool for predicting PDH after eTSS for PAs and demonstrated good generalizability. Patients could benefit from early identification of PDH and optimized treatment decisions.

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.

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.

Development and Validation of Nomogram to Preoperatively Predict Intraoperative Cerebrospinal Fluid Leakage in Endoscopic Pituitary Surgery: A Retrospective Cohort Study

Background

Pituitary adenomas (PAs) are the most common tumor of the sellar region. PA resection is the preferred treatment for patients with clear indications for surgery. Intraoperative cerebrospinal fluid (iCSF) leakage is a major complication of PA resection surgery. Risk factors for iCSF leakage have been studied previously, but a predictive nomogram has not yet been developed. We constructed a nomogram for preoperative prediction of iCSF leakage in endoscopic pituitary surgery.

Methods

A total of 232 patients who underwent endoscopic PA resection at the Department of Neurosurgery in Jinling Hospital between January of 2018 and October of 2020 were enrolled in this retrospective study. Patients treated by a board-certified neurosurgeon were randomly classified into a training cohort or a validation cohort 1. Patients treated by other qualified neurosurgeons were included in validation cohort 2. A range of demographic, clinical, radiological, and laboratory data were acquired from the medical records. The Least Absolute Shrinkage and Selection Operator (LASSO) algorithm and uni- and multivariate logistic regression were utilized to analyze these features and develop a nomogram model. We used a receiver operating characteristic (ROC) curve and calibration curve to evaluate the predictive performance of the nomogram model.

Results

Variables were comparable between the training cohort and validation cohort 1. Tumor height and albumin were included in the final prediction model. The area under the curve (AUC) of the nomogram model was 0.733, 0.643, and 0.644 in training, validation 1, and validation 2 cohorts, respectively. The calibration curve showed satisfactory homogeneity between the predicted probability and actual observations. Nomogram performance was stable in the subgroup analysis.

Conclusions

Tumor height and albumin were the independent risk factors for iCSF leakage. The prediction model developed in this study is the first nomogram developed as a practical and effective tool to facilitate the preoperative prediction of iCSF leakage in endoscopic pituitary surgery, thus optimizing treatment decisions.

A Nomogram for Preoperatively Predicting the Ki-67 Index of a Pituitary Tumor: A Retrospective Cohort Study

Background

The Ki-67 index is an indicator of proliferation and aggressive behavior in pituitary adenomas (PAs). This study aims to develop and validate a predictive nomogram for forecasting Ki-67 index levels preoperatively in PAs.

Methods

A total of 439 patients with PAs underwent PA resection at the Department of Neurosurgery in Jinling Hospital between January 2018 and October 2020; they were enrolled in this retrospective study and were classified randomly into a training cohort (n = 300) and a validation cohort (n = 139). A range of clinical, radiological, and laboratory characteristics were collected. The Ki-67 index was classified into the low Ki-67 index (<3%) and the high Ki-67 index (≥3%). Least absolute shrinkage and selection operator algorithm and uni- and multivariate logistic regression analyses were applied to identify independent risk factors associated with Ki-67. A nomogram was constructed to visualize these risk factors. The receiver operation characteristic curve and calibration curve were computed to evaluate the predictive performance of the nomogram model.

Results

Age, primary-recurrence subtype, maximum dimension, and prolactin were included in the nomogram model. The areas under the curve (AUCs) of the nomogram model were 0.694 in the training cohort and 0.658 in the validation cohort. A well-fitted calibration curve was also generated for the nomogram model. A subgroup analysis revealed stable predictive performance for the nomogram model. A correlation analysis revealed that age (R = −0.23; p < 0.01), maximum dimension (R = 0.17; p < 0.01), and prolactin (R = 0.16; p < 0.01) were all significantly correlated with the Ki-67 index level.

Conclusions

Age, primary-recurrence subtype, maximum dimension, and prolactin are independent predictors for the Ki-67 index level. The current study provides a novel and feasible nomogram, which can further assist neurosurgeons to develop better, more individualized treatment strategies for patients with PAs by predicting the Ki-67 index level preoperatively.

The Biochemical Diagnosis of Acromegaly

Background: The diagnosis of acromegaly still poses a clinical challenge, and prolonged diagnostic delay is common. The most important assays for the biochemical diagnosis and management of acromegaly are growth hormone (GH) and insulin-like growth factor-1 (IGF-1). Objective: Discuss the role of IGF-1, basal serum GH, and nadir GH after oral glucose tolerance test (OGTT) for the diagnosis, management, and treatment of patients with acromegaly. Methods: We performed a narrative review of the published data on the biochemical diagnosis and monitoring of acromegaly. An English-language search for relevant studies was conducted on PubMed from inception to 1 January 2021. The reference lists of relevant studies were also reviewed. Results: Serum IGF-1 levels, basal GH values, and nadir GH after OGTT play a major role in the diagnosis, management, and treatment of patients with acromegaly. Measurement of IGF-1 levels is the key factor in the diagnosis and monitoring of acromegaly, but basal and nadir GH following OGTT are also important. However, several factors may significantly influence the concentrations of these hormones, including assay methods, physiologic and pathologic factors. In some cases, discordant GH and IGF-1 levels may be challenging and usually requires additional data and monitoring. Conclusion: New GH and IGF-1 standards are much more precise and provide more accurate tools to diagnose and monitor patients with acromegaly. However, all these biochemical tools have their limitations, and these should be taken under consideration, along with the history, clinical features and imaging studies, when assessing patients for acromegaly.