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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Practical Approaches To Diagnosis And Treatment Of Acromegaly


Goal
To provide healthcare providers with up-to-date information regarding the diagnosis and treatment of acromegaly. 

Target Audience
This activity is designed for general internists, family practitioners, nurse practitioners, physician assistants, dentists, neurosurgeons, and endocrinologists. No prerequisites required.

Accreditation Statement
The Institute for Johns Hopkins Nursing, the Johns Hopkins University School of Medicine, and the Harvard School of Dental Medicine takes responsibility for the content, quality, and scientific integrity of this CE activity. At the conclusion of this activity, participants should be able to:

  • Examine the prevalence and impact of acromegaly in the United States.
  • Discuss current understanding of the pathophysiology of the disease.
  • Identify optimal methods of early detection, including nonendocrine specialist education and increasing
     community awareness.
  • Review the current diagnostic methods and how to best employ them for disease monitoring.

Accreditation Statement
The Institute for Johns Hopkins Nursing is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation.

The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Harvard School of Dental Medicine is an American Dental Association Continuing Education Recognition Program recognized provider.

Credit Designation Statement
The Institute for Johns Hopkins Nursing designates this activity for a maximum of
2.4 contact hours. The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award. The Harvard School of Dental Medicine designates this educational activity for a maximum of 2 CE credits toward the ADA CERP. Each participant should claim only those hours that he/she actually spent in the activity.

The estimated time to complete this educational activity: 2 hours.

Release date: February 15, 2005. Expiration date: February 15, 2007.

Disclaimer Statement
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Institute for Johns Hopkins Nursing, the Johns Hopkins University School of Medicine, and the Harvard School of Dental Medicine names implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is made possible by an unrestricted educational grant from Novartis Pharmaceuticals.

Full Disclosure Policy Affecting CE Activities:
It is the policy of the accrediting institutions to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Directors and Participating Faculty reported the following:

PROGRAM DIRECTORS

Marie Cook, RN, BSN
Coordinator, Neuro-Endocrine Testing Unit
Department of Medicine
Oregon Health and Science University
Portland, Oregon
Ms Cook reports serving as a consultant for Genentech, Novartis, and Pfizer Inc; and receiving honoraria from Genentech, Novartis, and Pfizer Inc.

Bruce R. Donoff, DMD, MD
Dean, Harvard School of Dental Medicine
Boston, Massachusetts
Dr Donoff reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Marjorie E. Ewertz, BSN
Instructor, Johns Hopkins University School of Nursing
Research Nurse Program Coordinator,
  Johns Hopkins University School of Medicine,
  Division of Endocrinology
Nurse Coordinator, Johns Hopkins Thyroid
  Tumor Center
Nurse Coordinator, Kelly G. Ripken Program for
  Thyroid Education and Patient Care at Johns Hopkins
Nurse Coordinator, Nuclear Medicine Thyroid
  Consultation Service
Division of Endocrinology and Metabolism
Johns Hopkins University School of Medicine
Baltimore, Maryland
Ms Ewertz reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Roberto Salvatori, MD, FACE
Assistant Professor of Endocrinology
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Salvatori reports receiving grants/research support from Genentech; and serving on the speaker bureau for Pfizer Inc.

PARTICIPATING FACULTY

Coleen Caster, RNC, MN, FNP
Director of Clinical Systems Redesign
Bulfinch Medical Group
Massachusetts General Hospital
Boston, Massachusetts
Ms Caster reports having no significant financial or advisory relationships with corporate organizations related to this activity.

David Cook, MD
Professor of Medicine 
Department of Medicine
Oregon Health and Science University
Portland, Oregon
Dr Cook reports receiving grants/research support from Eli Lilly and Company, Genentech, and Pfizer Inc; serving as a consultant for Genentech and Pfizer Inc; and receiving honoraria from Eli Lilly and Company, Genentech, and Pfizer Inc.

Laurence Katznelson, MD
Pituitary Center
Department of Neurosurgery and Medicine
Stanford Cancer Center
Stanford University
Stanford, California
Dr Katznelson reports serving as a consultant for Ipsen; and receiving honoraria from Novartis and Pfizer Inc.

Teresa Kidder-Moore, RN
Clinical Research Coordinator
NYU School of Medicine
Manhattan VA Administration Hospital
New York, New York
Ms Kidder-Moore reports receiving honoraria from Novartis.

Notice: Faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Practical Approaches To Diagnosis And Treatment Of Acromegaly
David Cook, MD*

Acromegaly is a rare disorder, the result of a noncancerous tumor (adenoma) of the pituitary that results in hypersecretion of a growth hormone, which stimulates overproduction of insulin-like growth factor 1. Incidental pituitary adenomas are surprisingly common, found in 10% to 20% of the US population at autopsy. These incidental tumors, defined as hormonally inactive, may never grow large enough to cause clinical signs or symptoms. However, hormonally active tumors may not present as large tumors, but very commonly they cause signs and symptoms related to hormonal excesses resulting in increased morbidity and mortality if left untreated.1,2 Tumors causing acromegaly occur annually in 3 to 4 of every 1 million people in every population studied. The number of patients diagnosed with acromegaly in the United States is unknown. There is a delay in diagnosis averaging 10 years. It seems reasonable to assume that the number of cases diagnosed is far lower than the actual number of cases of acromegaly in the population.3 Onset can be prepubertal, resulting in excess linear growth (referred to as gigantism) or postpubertal, resulting in the more disfiguring facial bone changes, such as frontal bossing and mandibular bone enlargement leading to dental malocclusion.

The onset of clinical changes in acromegaly is slow and subtle, and diagnosis of the disorder, as mentioned earlier in this article, remains undetected for an average of 10 years.3 The first signs and symptoms can be quite nonspecific, including headache, visual field loss, fatigue, hypertension, excessive perspiration, and joint pain. These vague manifestations make early diagnosis difficult.

Acromegaly causes significant morbidity and mortality. The disorder is associated with decreased life span through the increased risk of life-threatening conditions, such as cardiovascular disease, hypertrophic cardiomyopathy, and possibly colon cancer.

Positive outcomes have been difficult to achieve with acromegaly treatments. The current pharmacotherapies are relatively new. However, more troublesome is the insidious onset and low incidence of acromegaly. Most healthcare practitioners do not consider acromegaly as a possible cause for the more common presenting symptoms (eg, headache, diabetes, carpal tunnel syndrome, or joint pain). The average patient may not have heard of this disorder.

This monograph provides a basic knowledge of acromegaly to practitioners who frequently interact with patients—practitioners in primary care and those practitioners in certain specialties that require regular patient visits (eg, obstetrics/gynecology, dentistry). Dr Laurence Katznelson, neuroendocrinologist, provides a useful review of the etiology, pathogenesis, presentation, and treatment options and strategies for acromegaly. He also offers an important discussion on the presentation clues that should trigger a diagnosis of acromegaly.

Marie Cook, RN, BSN, an endocrinology nurse, continues this discussion by further exploring the early signs and symptoms of acromegaly and the nurse's role in recognizing and diagnosing the disorder, administering treatment, and providing the psychological support for these patients who suffer physically and emotionally. Nurses in many clinical settings must be prepared for the levels of patient treatment that are required for successful outcomes.

Perhaps most intriguing about this monograph is the case study, which highlights an actual acromegalic patient who is also a nurse. Coleen Caster, RNC, MN, FNP, offers her compelling story of the long journey to diagnosis with, in retrospect, many of the more serious symptoms that clearly signaled acromegaly. Teresa Kidder-Moore, RN, another endocrinology nurse and clinical research coordinator in neuroendocrinology, provides a discussion on the signs and symptoms that were missed or misdiagnosed by Coleen's various healthcare practitioners. A brief introduction to this case is included in this monograph. The full version, including a video of Coleen's case study, is available at www.acromegalyonline.com.

Healthcare practitioners in frequent contact with their patients can act as the sentinels for endocrinologists and patients with acromegaly by including acromegaly during differential diagnosis. Acromegaly is too rare a disorder for screening diagnosis, but given  the serious consequences of this pituitary adenoma and the benefits of treatment if initiated early, it is worth the effort for clinicians to become more familiar with this disorder.


REFERENCES
1. Molitch ME, Russell EJ. The pituitary "incidentaloma." Ann Intern Med. 1990;112:925-931.
2. Hall WA, Luciano MG, Doppman JL, et al. Pituitary magnetic resonance imaging in normal human volunteers: occult adenomas in the general population. Ann Intern Med. 1994;120:817-820.
3. Nabarro JD. Acromegaly. Clin Endocrinol (Oxf). 1987; 26:481-512.

*Professor of Medicine, Department of Medicine, Oregon Health and Science University, Portland, Oregon.
Address correspondence to: David Cook, MD, Professor of Medicine, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239. E-mail:
cookd@ohsu.edu.





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