The cost of a patient activation intervention for achieving successful outcomes: results from the PAADRN randomized controlled trial.

In a large, pragmatic clinical trial, we calculated the costs of achieving four successful patient-centered outcomes using a tailored patient activation DXA result letter accompanied by a bone health brochure. The cost to achieve one successful outcome (e.g., a 0.5 standard deviation improvement in care satisfaction) ranged from $127.41 to $222.75. INTRODUCTION: Pragmatic randomized controlled trials (RCTs) should focus on patient-centered outcomes and report the costs for achieving those outcomes. We calculated per person incremental intervention costs, the number-needed-to-treat (NNT), and incremental per patient costs (cost per NNT) for four patient-centered outcomes in a direct-to-patient bone healthcare intervention. METHODS: The Patient Activation after DXA Result Notification (PAADRN) pragmatic RCT enrolled 7749 patients presenting for DXA at three health centers between February 2012 and August 2014. Interviews occurred at baseline and 52 weeks post-DXA. Intervention subjects received an individually tailored DXA result letter accompanied by an educational bone health brochure 4 weeks post-DXA, while the usual care subjects did not. Outcomes focused on patients (a) correctly identifying their results, (b) contacting their providers, (c) discussing their results with their providers, and (d) satisfaction with their bone healthcare. NNTs were determined using intention-to-treat linear probability models, per person incremental intervention costs were calculated, and costs per NNT were computed. RESULTS: Mean age was 66.6 years old, 83.8% were women, and 75.3% were non-Hispanic whites. The incremental per patient cost (costs per NNT) to increase the ability of a patient to (a) correctly identify their DXA result was $171.07; (b) contact their provider about their DXA result was $222.75; (c) discuss their DXA result with their provider was $193.55; and (d) achieve a 0.5 SD improvement in satisfaction with their bone healthcare was $127.41. CONCLUSION: An individually tailored DXA result letter accompanied by an educational brochure can improve four patient-centered outcomes at a modest cost. TRIAL REGISTRATION: clinicaltrials.gov identifier NCT01507662.

Guidelines for acromegaly management: an update.

OBJECTIVE: The Acromegaly Consensus Group reconvened in November 2007 to update guidelines for acromegaly management. PARTICIPANTS: The meeting participants comprised 68 pituitary specialists, including neurosurgeons and endocrinologists with extensive experience treating patients with acromegaly. EVIDENCE/CONSENSUS PROCESS: Goals of treatment and the appropriate imaging and biochemical and clinical monitoring of patients with acromegaly were enunciated, based on the available published evidence. CONCLUSIONS: The group developed a consensus on the approach to managing acromegaly including appropriate roles for neurosurgery, medical therapy, and radiation therapy in the management of these patients.

Pituitary production of prolactin and prolactin-suppressing drugs.

Prolactin secretion from the anterior pituitary is mediated via dopaminergic pathways. Any process that alters dopamine production or transport in the central nervous system may lead to hyperprolactinemia. Most cases of hyperprolactinemia are due to prolactin secreting pituitary tumors or to medications which alter dopamine production. Prolactinomas cause amenorrhea, galactorrhea and infertility in women and impotence and neurological deficits in men. Dopamine receptor agonists are the mainstay of therapy for hyperprolactinemia as they rapidly lower serum prolactin and cause tumor shrinkage. In this paper we review the regulation of prolactin secretion, the clinical features and causes of hyperprolactinemia, and the use of dopamine agonists.

Illness episodes and cortisol in healthy older adults during a life transition.

Alterations in neuroendocrine functioning and in the neuroendocrine response to stress have been observed in older adults. Stressful life events have also been associated with increased illness vulnerability. However effects of natural life stressors on neuroendocrine functioning and health of the elderly have not been well characterized. This research examines relationships among cortisol, dehydroepiandrosterone sulfate (DHEA-S), distress, and illness episodes in an elderly population experiencing the life transition of housing relocation. Thirty older adults moving to congregate livingfacilities were assessed in their homes 1 month premove and 2 weeks postmove. Twenty-eight nonmoving comparison participants were assessed at similar time points. Assessments included measures of intrusion, cortisol, DHEA-S, and self-reported infectious illness episodes. Movers reported more illness episodes between the two assessments than controls. Significant alterations in neuroendocrine measures were not observed among movers at either time point. Individuals with more intrusive thoughts had higher cortisol levels concurrently and prospectively, but these relationships did not vary by group. Greater intrusion at premove was associated with a greater likelihood of reported illness episodes between the two assessments, but there were no relationships between neuroendocrine factors and illness episodes, and intrusion did not mediate the relationships between group and likelihood of illness. In healthy elders, a temporary life stressor may increase vulnerability to illness but does not

The relationship between the density of the alveolar processes and that of post-cranial bone.

Skeletal mass declines in all populations with age, and the literature suggests that changes in oral bone may be linked to the status of the post-cranial (systemic) skeleton. However, there is a lack of information defining the relationship between alveolar process bone and the post-cranial skeleton in healthy individuals. The purpose of this study was to determine: (1) if the bone densities of the maxillary and mandibular alveolar processes are related to the bone density of the spine, hip, or radius in healthy women; and (2) if the alveolar process densities decline with age. Forty-one dentate Caucasian women aged 20 to 78 years underwent assessment of post-cranial (systemic) and alveolar process bone. D-speed vertical bitewing and periapical radiographs incorporating aluminum stepwedges, controlled exposure and processing conditions, and a density correction algorithm were used to make alveolar process density assessments with regions of interest (ROIs) apical to crestal bone and intrabony defects. Anteroposterior lumbar (L1 to L4) and lateral lumbar (L2 to L4) spine, total hip (and subregions), and radius bone densities were determined by dual-energy x-ray absorptiometry (DEXA). Correlation analysis revealed significant relationships between maxillary alveolar process bone density and the density of the mandibular alveolar process (r = 0.57, p < or = 0.001), anteroposterior lumbar spine (r = 0.53, p < or = 0.001), lateral lumbar spine (r = 0.52, p < or = 0.001), total hip (r = 0.39, p = 0.01), total radius (r = 0.39, p = 0.01), and age (r = -0.38, p = 0.01). A two-tailed t test comparison revealed significantly greater maxillary alveolar process bone density in women younger than 50 years of age than in those 50 and older (p < or = 0.01). We conclude that the density of maxillary alveolar process bone is significantly related to the density of the mandibular alveolar process, lumbar spine, hip, and radius in healthy women and that maxillary alveolar process bone density declines with age.

Osteoporosis and osteopenia in men with eating disorders.

The occurrence of eating disorders and related deficiencies in bone mineral density are well established in women. However, we provide evidence that eating disorders are as common in men as in women, and are perhaps more severe.

Effects of prolactin in stimulating disease activity in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE), a chronic autoimmune illness, is influenced by hormones. High prolactin concentrations were associated with early death from autoimmune renal disease in NZB/NZW mice, an animal model of severe SLE. NZB/NZW mice that delivered and nursed pups and those that underwent pseudopregnancy had changes in serum IgG and autoantibodies. NZB/NZW mice treated with the prolactin-suppressing drug bromocriptine had prolonged lives. Elevated serum prolactin concentrations are reported in SLE patients of both sexes. We found four women with long-standing hyper-prolactinemia who developed SLE. A survey of premenopausal women whose sera were submitted for autoantibody testing showed that 20% with anti-ds-DNA antibodies also had high prolactin levels. Many hyperprolactinemic patients whose sera were referred to an endocrinology laboratory had positive FANA tests (women 33%, men 53%) but did not have SLE. Disease activity was suppressed in six of seven SLE patients treated with bromocriptine. All had elevated disease activity and five became unexpectedly hyperprolactinemic after treatment stopped. Manipulating serum prolactin affords a means of treating clinical SLE activity.

Factors associated with primary care residents' satisfaction with their training.

BACKGROUND AND OBJECTIVES: Satisfaction is known to impact work performance, learning, recruitment, and retention. This study identifies the factors associated with primary care residents' satisfaction with their training. METHODS: We used a cross-sectional survey based on the Price-Mueller model of job satisfaction. The model included 14 job characteristics, four personal characteristics, and four demographic factors. Data were collected in February and March 1996 from residents in three primary care training programs (family practice, pediatrics, and internal medicine) at a large academic medical center. The same standardized, self-administered questionnaires were used in all three departments. RESULTS: Seventy-five percent (n = 119) of the residents returned questionnaires. Five job characteristics were positively associated with resident satisfaction: continuity of care, autonomy, collegiality, work that encourages professional growth, and work group loyalty. Role conflict, a sixth job characteristic, was negatively associated with satisfaction. The personal characteristic of having an optimistic outlook on life was also positively associated with satisfaction. The model explained 66% of the variation in self-reported satisfaction. CONCLUSIONS: The satisfaction of the residents was significantly associated with six job characteristics and one personal factor. Interventions based on these job characteristics may increase resident satisfaction and may lead to better patient outcomes, better work performance, greater patient satisfaction, and more success in recruiting top students into a residency.

Clinical impact of hyperprolactinaemia.

Prolactinomas are benign, functioning pituitary tumours that cause reproductive dysfunction in men and women. PRL-secreting microadenomas have a benign clinical course and may even disappear without treatment. Absolute indications for treatment of hyperprolactinaemia include the need to restore fertility and the presence of a macroadenoma. A dopamine agonist is the treatment of choice regardless of tumour size and will normalize PRL and restore menses in the majority of cases. Hypogonadism induced by hyperprolactinaemia is associated with decreased spinal bone mineral content, but it is not clear whether the bone loss is progressive. Bone mass improves after treatment of the hyperprolactinaemia but does not normalize. The safety of chronic oestrogen therapy in women with hyperprolactinaemic amenorrhoea who are not desirous of fertility remains to be elucidated by ongoing clinical trials.

Sequential MR enhancement pattern in normal pituitary gland and in pituitary adenoma.

PURPOSE: To measure and evaluate the temporal enhancement characteristics of the normal pituitary gland and pituitary adenoma. METHODS: Thirty healthy subjects and 10 patients with sellar pituitary adenomas were studied prospectively using dynamic MR imaging with a 5- or 10-sec temporal resolution during a bolus injection of gadolinium. RESULTS: Qualitative visual analysis demonstrated a consistent sequential pattern of pituitary enhancement in which the posterior lobe enhanced earlier than the anterior lobe by approximately 35 sec. Quantitative analysis revealed that posterior lobe enhancement occurred 9.8 +/- 1.5 sec (mean +/- SEM) before the anterior lobe in healthy subjects, whereas tumor enhancement occurred significantly before the anterior lobe but only slightly before the posterior lobe in patients with adenomas. CONCLUSION: The sequential enhancement pattern of the normal pituitary gland was found to be consistent with its vascular anatomy. In contrast to previous reports, pituitary adenomas were found to enhance earlier than the anterior lobe. These results suggest that pituitary adenomas have a direct arterial blood supply, similar to that of the posterior pituitary lobe.

Contemporary therapy of prolactin-secreting adenomas.

Prolactin-secreting pituitary tumors are common benign pituitary neoplasm that cause amenorrhea, galactorrhea, and infertility. Inhibition of prolactin secretion by a dopamine agonist restores menses and reduces tumor size. This article outlines an approach to therapy and discusses the use of estrogen in women with prolactinomas.

Neurologic complications of thyroid and parathyroid disease.

Common thyroid and parathyroid disorders present with reversible neurologic signs and symptoms affecting the central and peripheral nervous system, musculature, and mental function. Patients with thyrotoxicosis may have myopathy, spasticity, seizures, and multiple psychiatric symptoms. A deficiency of thyroid hormone also causes muscle weakness and may be accompanied by reversible muscle hypertrophy or movement disorders. The chronic hypercalcemia that develops secondary to hyperparathyroidism produces many psychiatric and cognitive symptoms, as well as a reversible myopathy. Calcium deficiency leads to neuromuscular irritability, paresthesias, and tetany. Psychiatric disorders are also common in this disorder.

A longitudinal analysis of premenopausal bone loss in healthy women and women with hyperprolactinemia.

In this report we describe longitudinal measurements of forearm and spinal bone mineral in healthy women and women with hyperprolactinemia. One hundred and ten women underwent yearly assessment of forearm and spinal bone mineral by single photon absorptiometry and computed tomography for an average of 4.7 yr. At entry into the study, women with hyperprolactinemic amenorrhea had 21% lower spinal bone mineral and 2.5% lower forearm bone mineral than healthy premenopausal women. Despite decreased estradiol levels (31 +/- 23 pmol/L), spinal bone in women with hyperprolactinemic amenorrhea did not change over time (+0.08%/yr; P = 0.89). In contrast, spinal bone in healthy women with regular menses (mean age, 34.6 +/- 6.6 yr) decreased significantly (1.7%/yr; P = 0.01). Cortical bone in the forearm did not change in either group. The hyperprolactinemic subjects had higher body mass index (28 +/- 6 vs. 24 +/- 4 kg/m2) and serum testosterone (0.5 +/- 0.2 vs. 0.39 +/- 0.16 pmol/L) than control subjects, but neither parameter correlated with bone loss. Although 64% of the hyperprolactinemic subjects had serum estradiol levels below 30 pmol/L, there was no correlation between estradiol or duration of amenorrhea and bone loss. Women with normal PRL levels and regular menses 3-9 yr after treatment of hyperprolactinemia had significantly lower spinal bone mineral (147 +/- 28 mg/mL) than healthy premenopausal women (169 +/- 29 mg/mL) and showed no change in spinal bone (+0.3%/yr; P = 0.67) over 5 yr. Despite significant hypoestrogenemia, women with hyperprolactinemic amenorrhea did not evidence a rapid decline in spinal bone. Restoration of gonadal function was not associated with normalization of bone mineral. The bone loss that accompanies hyperprolactinemia is not comparable to that which occurs after oophorectomy or menopause. These findings raise important questions about the importance of osteopenia as an indication for treatment of hyperprolactinemic amenorrhea.

Intracranial dissemination of an ACTH secreting pituitary neoplasm--a case report and review of the literature.

A 52-year-old woman developed recurrent hypercortisolism 3 yr after successful surgical treatment of Cushing's disease. At postmortem, eosinophilic pituitary tissue showing positive ACTH immunohistochemical staining was present in the frontal lobe and cerebellum but there was no tumor in the sella. In the absence of a pituitary tumor, extrasellar ACTH producing tissue could arise from seeding of the cerebrospinal fluid with tumor cells at the time of operation or from an atypical pituitary carcinoma. In this report we review the mechanisms of intracranial dissemination of pituitary tissue and ACTH-secreting pituitary carcinomas, including parasellar invasion, meningeal seeding, and cerebrospinal and hematogenous spread.