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Within New York State, significant geographic variation exists in the cost for transsphenoidal pituitary surgery. The significance of and contributors to such variation is an important question for patients, providers, and policy makers. Transparency of hospital charges, costs, and average length of stay for procedures to the public provides useful information for informed decision-making, especially for a highly portable disease entity like pituitary tumors.

Type 1 diabetes mellitus (T1D) is characterized by a heightened antibody (Ab) response to pancreatic islet self-antigens, which is a biomarker of progressive islet pathology. We recently identified a novel antibody to clade B serpin that reduces isletassociated T cell accumulation and is linked to the delayed onset of T1D. As natural immunity to clade B arises early in life, we hypothesized that it may influence islet development during that time. To test this possibility healthy young Balb/c male mice were injected with serpin B13 mAb or IgG control and examined for the number and cellularity of pancreatic islets by immunofluorescence and FACS. Beta cell proliferation was assessed by measuring nucleotide analog 5-ethynyl-2-deoxyuridine (5-EdU) incorporation into the DNA and islet Reg gene expression was measured by real time PCR. Human studies involved measuring anti-serpin B13 autoantibodies by Luminex. We found that injecting anti-serpin B13 monoclonal Ab enhanced beta cell proliferation and Reg gene expression, induced the generation of ϳ80 pancreatic islets per animal, and ultimately led to increase in the beta cell mass. These findings are relevant to human T1D because our analysis of subjects just diagnosed with T1D revealed an association between baseline anti-serpin activity and slower residual beta cell function decline in the first year after the onset of diabetes. Our findings reveal a new role for the anti-serpin immunological response in promoting adaptive changes in the endocrine pancreas and suggests that enhancement of this response could potentially help impede the progression of T1D in humans. Type 1 diabetes mellitus (T1D)3 is an autoimmune condition that affects people of all ages. Although T1D was traditionally considered a pediatric disease, it has become clear that individuals over 20 years old can also develop detectable autoimmunity against pancreatic islets with concomitant sudden onset of insulin dependence (1). To date, the modifying factors that precipitate the clinical manifestation of autoimmune diabetes at different ages are largely unknown.We have focused on factors that regulate the timing of clinical onset of T1D. Recent observations from our laboratory have revealed a novel autoantibody directed against the serpin B13 protease inhibitor (2, 3) and demonstrated that it partially protects against early onset autoimmune diabetes (4). In T1D susceptible nonobese diabetic (NOD) mice, elevated secretion of anti-serpin B13 autoantibody is associated with protection from diabetes before 16 weeks of age, whereas decreased secretion of this antibody (Ab) in humans is associated with T1D onset before age 5 years (4). These observations suggest an inverse relationship between the serpin B13 autoantibody response and the appearance of the clinical features of T1D. We further linked the serpin Ab to reduced autoimmune inflammation in pancreatic islets, likely due to enhanced extracellular cleavage of key cell surface molecules expressed in T and B cells (5). Of note, serpins have been impl...

SummaryCo-secretion of growth hormone (GH) and prolactin (PRL) from a single pituitary adenoma is common. In fact, up to 25% of patients with acromegaly may have PRL co-secretion. The prevalence of acromegaly among patients with a newly diagnosed prolactinoma is unknown. Given the possibility of mixed GH and PRL co-secretion, the current recommendation is to obtain an insulin-like growth factor-1 (IGF-1) in patients with prolactinoma at the initial diagnosis. Long-term follow-up of IGF-1 is not routinely done. Here, we report two cases of well-controlled prolactinoma on dopamine agonists with the development of acromegaly 10–20 years after the initial diagnoses. In both patients, a mixed PRL/GH-cosecreting adenoma was confirmed on the pathology examination after transsphenoidal surgery (TSS). Therefore, periodic routine measurements of IGF-1 should be considered regardless of the duration and biochemical control of prolactinoma.Learning points:Acromegaly can develop in patients with well-controlled prolactinoma on dopamine agonists.The interval between prolactinoma and acromegaly diagnoses can be several decades.Periodic screening of patients with prolactinoma for growth hormone excess should be considered and can 
lead to an early diagnosis of acromegaly before the development of complications.

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