Real-world comorbidities and treatment patterns of patients with acromegaly in two large US health plan databases

Acromegaly is a rare, chronic, and debilitating disease that results from excessive growth hormone production. Clinically, this disease is associated with enlargement of soft tissue, excessive skeletal growth, and increased risk of cardiovascular disease. Acromegaly is often diagnosed late, when a wide range of comorbidities may already be present. First-line therapy for acromegaly is typically surgery; but a number of highly-specific pharmacological agents have recently enabled a more aggressive medical management of acromegaly. Since surgical cure of acromegaly is low for macroadenomas, medical control of active acromegaly is an important component of treatment. There are no published US data currently available regarding real-world rates of comorbidities and treatment patterns among patients with acromegaly. This retrospective study examined the comorbidities and treatment patterns of 949 health plan enrollees, who had acromegaly diagnosis and/or procedure codes in an administrative claims database from July 1, 2002 through June 30, 2010. Acromegaly was associated with high rates of hypertension and diabetes along with a number of other comorbidities. The incidence of comorbidities was highest among patients with acromegaly-related treatment, which may have resulted, in part, from inadequate disease management and/or poor disease control. Unexpectedly, 55 % of patients identified with acromegaly received no treatment for acromegaly (i.e., surgery, radiotherapy, and medication) and only 28 % received a medication treatment during the observation period. However, some patients may have received a curative surgery prior to the observation period, which may have reduced the use of other acromegaly-related treatments during the study period. Of those treated with medications, the most common first medications were octreotide, cabergoline, and bromocriptine. Given the high incidence of serious comorbidities associated with active acromegaly, earlier diagnosis and treatment, along with appropriate follow-up care, may potentially avoid the life-long consequences of uncontrolled disease.     

Housing Dependence and Intimate Relationships in the Lives of Low-Income Puerto Rican Mothers

Using longitudinal ethnographic data from the Three-City Study, we examined the relationship between sixteen low-income Puerto Rican mothers' housing dependencies and their intimate partner relations. We traced mothers' dependent housing arrangements and entrée to marital or cohabiting relationships from their teens through their procurement of independent housing while entering and maintaining intimate partner unions as adults. Findings indicated that various trigger factors led women out of their natal homes and into expedited cohabitation with romantic partners which frequently resulted in unstable unions in which mothers had little power and autonomy. As mothers became eligible for housing subsidies they obtained housing independent from their male partners, potentially increasing the propensity for greater relationship power. Housing independence, however, was not without problems. Spillover effects, such as shadowing partners, threatened housing stability and mothers' independence. The relevance of these findings for future research is discussed.     

Placental efficiency and adaptation: endocrine regulation

Size at birth is critical in determining life expectancy and is dependent primarily on the placental supply of nutrients. However, the fetus is not just a passive recipient of nutrients from the placenta. It exerts a significant acquisitive drive for nutrients, which acts through morphological and functional adaptations in the placenta, particularly when the genetically determined drive for fetal growth is compromised by adverse intrauterine conditions. These adaptations alter the efficiency with which the placenta supports fetal growth, which results in optimal growth for prevailing conditions in utero . This review examines placental efficiency as a means of altering fetal growth, the morphological and functional adaptations that influence placental efficiency and the endocrine regulation of these processes.     

Hemorrhagic tumor necrosis during a pilot trial of tumor necrosis factor-alpha and anti-GD3 ganglioside monoclonal antibody in patients with metastatic melanoma

Hemorrhagic tumor necrosis is an inflammatory event that leads to selective destruction of malignant tissues, with both potentially toxic and beneficial consequences. A pilot clinical trial was undertaken combining tumor necrosis factor-alpha (TNF-alpha) with the monoclonal antibody R24 (MoAb R24) against GD3 ganglioside in patients with metastatic melanoma. Patients received MoAb R24 to recruit leukocytes to the tumor followed by low doses of recombinant TNF-alpha to activate leukocytes. Eight patients were treated and seven patients had mild toxicity. One patient with extensive metastatic melanoma developed tumor lysis syndrome within hours after treatment with almost complete necrosis of bulky tumors in multiple visceral sites. To our knowledge, this is the first documented case of hemorrhagic tumor necrosis in a patient with metastatic cancer in multiple visceral sites.     

Detection of ischemic myocardium in vivo through the chest wall by quantitative ultrasonic tissue characterization

Quantitative analysis of ultrasound offers a potentially valuable method for noninvasive differentiation of specific types of cardiac disease and for assessment of their severity. Clinical application necessitates quantitative measurement of the ultrasonic properties of myocardium through the chest wall. This study was designed to determine whether such measurements could be made noninvasively with the aid of conventional M mode echocardiographic guidance and to characterize the quantitative effects of intervening tissue (chest wall) on the ultrasonic signals backscattered by ischemic and normal myocardium. Frequency-dependent ultrasonic backscatter (2 to 7 MHz) from normal myocardium was measured in dogs in vivo through the closed chest with the use of M mode guidance and with the chest open, directly from the myocardium. Closed-chest and open-chest measurements were repeated after ligation of the left anterior descending coronary artery in the same animals. Closed-chest data were compensated by correcting for the average value for the slope of the attenuation-frequency function of chest wall, which was determined from measurements obtained by analysis on excised tissue. Compensated closed-chest measurements correlated with measurements obtained from the epicardial surface of the heart. The differentiation of normal from ischemic myocardium with both the closed- and open-chest measurements was consistent (p < 0.005). The successful differentiation of normal from ischemic myocardium by determination of quantitative backscatter through the intervening chest wall supports the concept that tissue characterization by quantitative analysis of backscattered ultrasound is a potentially useful, clinically applicable approach to noninvasive detection and differentiation of intrinsic properties of normal and diseased myocardium.