The knowledge and attitudes of primary care physicians about acromegaly: a survey study with multinational participation

The knowledge and attitudes of primary care physicians about acromegaly: a survey study with multinational participation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The knowledge and attitudes of primary care physicians about acromegaly: a survey study with multinational participation Aysen Kutan Fenercioglu, Ebru Unur Demircan, Gunay Can, Cem Sulu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4351785/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Dec, 2024 Read the published version in BMC Primary Care → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Acromegaly is a disease with a high morbidity and mortality rate. The role of primary care physicians is very important in the early diagnosis of acromegaly. This study aims to determine the knowledge and attitudes of primary care physicians about acromegaly in different countries of the world. Methods: The survey, consisting of 33 questions prepared in English and Turkish, was applied to a total of 396 primary care physicians, 280 of whom were from Turkey, 84 from European countries, 28 from Asian countries, and 4 from Nigeria. Mostly, the survey was administered via Google Forms sent to social media groups of primary care physicians. Some of the surveys were applied face-to-face. The survey included 12 questions about the clinical manifestations, six questions about the diagnosis, 12 questions about the comorbidities, one question about the treatment, and two questions about the prognosis of acromegaly. Data about acromegaly knowledge and attitudes of physicians were evaluated using the Chi-square test. Results: The presence of acral findings in acromegaly was better known by Turkish physicians (96.8%) compared to Asian/African (84.4%) and European (84.5%) physicians (p<0.001). The presence of generalized visceromegaly and excessive sweating in acromegaly was better known by Asian/African physicians (p=0.01 and p=0.009). “Old photographs can be informative in patients suspected to have acromegaly”, the rate of correct answers to this question was higher in Turkish and Asian/African groups (p<0.001). Only 36.1% of Turkish physicians, 29.8% of European physicians, and 31.3% of Asian/African physicians knew that serum GH and IGF-1 levels were diagnostic tests for acromegaly. Although 64.3% of Turkish physicians knew that serum IGF-1 level was the single best test to be chosen in patients suspected to have acromegaly, the rate of the correct answers to this question was low in European (36.9%) and Asian/African (46.9%) physicians (p<0.001). Only 18.6% of Turkish and 13% of European physicians knew that surgery was the treatment of choice in acromegaly. The rate of correct answers to this question was higher in Asian/African physicians (59.4%) (p=0.003). Conclusion: The knowledge of primary care physicians about acromegaly should be increased through workshops, seminars, and subject-focused courses. Acromegaly Primary care knowledge attitudes Background Acromegaly is a rare, endocrinological disease caused by chronic excessive secretion of growth hormone and insulin-like growth factor-1 (IGF-1) [ 1 ]. Due to long-term exposure of tissues to growth hormone and IGF-1, many comorbidities such as cardiovascular, respiratory, metabolic, musculoskeletal, neurological, and neoplastic diseases may accompany [ 2 ]. In a review of studies, the prevalence of acromegaly ranged between 2.8 and 13.7 cases per 100,000 people and the annual incidence ranged between 0.2 and 1.1 cases per 100,000 people. The median age at diagnosis is in the fifth decade of life with a median diagnostic delay of 4.5–5 years [ 3 ]. Acromegaly is a disease with a high morbidity and mortality rate. Diagnosis on time reduces the mortality rate of patients and improves their quality of life [ 1 , 4 ]. Most acromegaly patients have pituitary macroadenoma and 60% of pituitary adenomas are pure somatotroph adenomas that secrete only growth hormone. Pituitary adenomas that secrete growth hormone together with prolactin are seen in 25% of cases. Adenomas that secrete TSH or ACTH along with growth hormone and carcinomas that secrete growth hormone are rare. Acromegaly is not observed in silent somatotroph adenomas that do not secrete growth hormone. Hypothalamic tumors that secrete Growth Hormone Releasing Hormone (GHRH) and pancreatic or bronchial carcinoid tumors may cause acromegaly by causing excessive secretion of growth hormone [ 5 ]. Multiple Endocrine Neoplasia type 1 and type 4, McCune-Albright syndrome, Carney complex, familial isolated pituitary adenoma, familial succinate dehydrogenase gene defects, and X-linked acrogigantism are different familial causes of acromegaly [ 1 , 2 , 6 ]. Due to the growth in soft tissues and bones, enlargement of the hands and feet and thickening of the fingers are observed in acromegaly patients. The patient's shoes and rings may become too small for him. Changes that occur on the face include prominence in the forehead, chin, and cheekbones, thickening of the lips, coarsening of facial lines due to nose widening, and malocclusion. There may be a hoarseness in the voice due to hypertrophy in the sinuses and larynx. Macroglossia may be seen [ 1 , 2 , 5 ]. The frequency of carpal tunnel syndrome, degenerative arthritis, and vertebral fractures is increased in acromegaly. Myalgia and arthralgia are observed in 30–70% of patients. Increased thickness and oiliness of the skin, increased sweating and acanthosis nigricans are skin findings. Generalized visceromegaly may occur [ 1 , 5 ]. Atherosclerosis, coronary artery disease, and cerebrovascular events may occur due to the chronic excessive secretion of growth hormone and IGF-1, endothelial dysfunction through increased endothelial proliferation, increased oxidative stress, and the impairment of oxidative defense mechanisms [ 7 ]. Hypertension is very common, seen in 20–50% of patients, and its prevalence increases as the duration of the disease increases. Cardiomyopathy, arrhythmias, hypertrophy of the heart muscle, congestive heart failure, and heart valve diseases are other cardiovascular complications [ 5 , 7 ]. In addition, diabetes mellitus, insulin resistance, glucose intolerance, hyperlipidemia, hypothyroidism, and goiter are metabolic complications. Increased body fat mass and an increase in total mass may occur. Frequent headaches, sleep apnea, oligomenorrhea, and carpal tunnel syndrome are atypical clinical manifestations associated with acromegaly [ 1 , 2 , 5 ]. The Endocrine Society clinical practice guidelines suggest screening for acromegaly by measurement of IGF-I in patients with typical clinical manifestations, but also in those who lack the typical clinical picture [ 8 ]. Factors that delay the diagnosis of acromegaly are the slow onset of acromegaly symptoms, the fact that physical findings occur over a long period and cannot be easily noticed by the patient and their relatives, the fact that patients consult different specialists for a wide range of complaints, and the fact that physicians do not consider the diagnosis of acromegaly. During this delay period, complications and the mortality rate increase [ 1 ]. Although clinical scoring systems and artificial intelligence programs have been developed over the years to assist physicians, the knowledge and attitudes of physicians are still the most important factors in diagnosing acromegaly. In the context of a comprehensive approach and specific problem-solving skills, the role of primary care physicians is crucial for diagnosing acromegaly for this wide range of clinical manifestations. This study aims to determine the knowledge and attitudes of primary care physicians about acromegaly in different countries of the world. Methods Study design and study population This cross-sectional descriptive study was conducted between December 2020 and November 2023 by applying a survey to a total of 396 primary care physicians from various nations. Data from 280 primary care physicians from Turkey, 84 from European countries, 28 from Asian countries, and 4 from Africa were obtained by this survey. The European physicians who participated in the study were from Germany, Netherlands, Romania, England, North Macedonia, Serbia, France, Sweden, Slovenia, Portugal, Spain, Belgium, Ireland, and Croatia. The Asian physicians who participated in the study were from Pakistan, Malaysia, Georgia, Israel, and Malta. The African physicians who participated in the study were from Nigeria. Data Collection The survey consisted of 33 questions prepared by A.K.F., P.K., C.S., and H.M.O. The survey was prepared in both English and Turkish. Twelve of the questions were related to the clinical manifestations of acromegaly, six of them were about the diagnosis of acromegaly, twelve of them were related to the comorbidities associated with acromegaly, one question was about the treatment and two questions were about the prognosis of acromegaly. Respondents were asked to respond “agree” or “disagree/have no idea” to the questions. Mostly, the survey was administered via Google Forms sent to social media groups of primary care physicians. Some of the surveys were applied face-to-face during primary care physicians' meetings and congresses. The face-to-face survey was administered by A.K.F. The whole survey took 15 minutes to complete. Statistical analysis Data about acromegaly knowledge and attitudes of Turkish physicians, European physicians, Asian, and African physicians were evaluated using the Chi-square test in Tables 1 , 2 , 3 , and 4 . P-values less than 0.05 were considered statistically significant. Data were entered and analyzed using SPSS for Windows version 16.0 (SPSS Inc; Chicago, IL, USA). Ethical considerations This study was conducted according to the Declaration of Helsinki. All physicians who participated in the study face-to-face signed a written informed consent before participating. Those who participated through a Google form approved the informed consent which was added to the questionnaire. The Clinical Research Ethics Committee of Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty (approval date and number 21.10.2020–139312), approved the study. Results Out of 396 physicians who participated in the study, 280 were from Turkey, 84 were from Europe, and 32 were from Asia and Africa. The comparison of the answers to the questions was made between these three groups in Tables 1 , 2 , 3 , and 4 . Table 1 shows the comparison of the knowledge of primary care physicians about clinical manifestations of acromegaly. There wasn’t any statistical significance in questions related to the visual findings of acromegaly and the majority of the physicians answered correctly to this question. The questions about the acral findings, excessive sweating, and generalized visceromegaly in acromegaly revealed statistical significance between the groups. The presence of acral findings in acromegaly was better known by Turkish physicians (96.8%) compared to Asian/African (84.4%) and European (84.5%) physicians (p < 0.001). Although the majority of Asian/African physicians (81,3%) knew that patients complaining of excessive sweating may have acromegaly, only half of the Turkish and European physicians answered correctly to this question. (p = 0.009). The presence of generalized visceromegaly in acromegaly was also better known by Asian/African physicians compared to Turkish and European physicians (78.1% vs 62.1% and 48.8%) (p = 0.01). Although the majority of the primary care physicians answered correctly to the question “Old photographs can be informative in patients suspected to have acromegaly”, the rate of correct answers to this question was higher in Turkish and Asian/African groups (p < 0.001). Galactorrhea is a finding that can be seen in acromegaly and half of the Turkish and Asian/African physicians disagreed with the misleading question about galactorrhea. There was a statistical significance in the comparison of the groups in this question (p = 0.01). Snoring in an underweight patient can be suggestive of acromegaly. This clinical finding was better known by Asian/African physicians (65%) compared to Turkish (28.6%) and European (44%) physicians (p < 0.001). Table 1 Answers about the Clinical Manifestations of Acromegaly Turkey (N = 280) Europe (N = 84) Asia and Africa (N = 32) P value N % N % N % I will consider the diagnosis of acromegaly in patients admitted with acral findings Disagree/ No idea 9 3.2 13 15.5 5 15.6 Agree 271 96.8 71 84.5 27 84.4 < 0.001 Patients with coarse facial features may have acromegaly disease Disagree/ No idea 14 5 4 4.8 0 0 Agree 266 95 80 95.2 32 100 0.435 Patients complaining of excessive sweating may have acromegaly Disagree/ No idea 132 47.1 38 45.2 6 18.8 Agree 148 52.9 46 54.8 26 81.3 0.009 Acromegaly patients may suffer from peripheral edema Disagree/ No idea 129 46.1 27 32.1 15 46.9 Agree 151 53.9 57 67.9 17 53.1 0.071 Old photographs can be informative in patients suspected to have acromegaly Disagree/ No idea 5 1.8 9 10.7 0 0 Agree 275 98.2 75 89.3 32 100 < 0.001 Acromegaly patients may present with headache Disagree/ No idea 40 14.3 18 21.4 3 9.4 Agree 240 85.7 66 78.6 29 90.6 0.174 Menstrual irregularity can be found in acromegaly patients Disagree/ No idea 42 15 18 21.4 2 6.3 Agree 238 85 66 78.6 30 93.8 0.113 Acromegaly patients may have generalized visceromegaly Disagree/ No idea 106 37.9 43 51.2 7 21.9 Agree 174 62.1 41 48.8 25 78.1 0.01 Galactorrhea is not seen in patients with acromegaly Agree/ No idea 124 44.3 50 59.5 15 46.9 Disagree 156 55.7 34 40.5 17 53.1 0.049 Acromegaly patients do not have gynecomastia Agree/ No idea 120 42.9 43 51.2 20 62.5 Disagree 160 57.1 41 48.8 12 37.5 0.063 Acromegaly patients may present with visual problems Disagree/ No idea 42 15.0 20 23.8 3 9.4 Agree 238 85.0 64 76.2 29 90.6 0.086 Snoring in an underweight patient can be suggestive of acromegaly Disagree/ No idea 200 71.4 47 56 11 34.4 Agree 80 28.6 37 44 21 65.6 < 0.001 Chi-square test Table 2 shows the comparison of the knowledge of the primary care physicians about the diagnosis of acromegaly. The diagnosis of acromegaly is mainly made by serum GH and IGF-1 levels and demonstration of pituitary adenoma by radiological imaging. Only 36.1% of Turkish physicians, 29.8% of European physicians, and 31.3% of Asian/African physicians knew that serum GH and IGF-1 levels are diagnostic tests for acromegaly. Although 64.3% of Turkish physicians knew that serum IGF-1 level is the single best test to be chosen in patients suspected to have acromegaly, the rate of the correct answers to this question was low in European (36.9%) and Asian/African (46.9%) physicians (p < 0.001). The rate of physicians who knew that the diagnosis of acromegaly should be made by demonstration of macroadenoma was higher in Asia/African (78.1%) compared to Turkish (59.3%) and European (52.4%) physicians (p = 0.041). Still, 100% of Asian/African physicians knew that asymptomatic patients with pituitary macroadenoma may have acromegaly. There was a statistical significance when this rate was compared with the rates of Turkish (63.6%) and European (46.4%) physicians (p < 0.001). Patients with acromegaly may have impaired glucose tolerance. Therefore, oral glucose tolerance testing is used in the diagnosis of acromegaly. The rate of physicians who answered correctly to the misleading question was higher among European physicians (57.1%) compared to Turkish (54.6%) and Asian/African (31.3%) physicians (p = 0.031). Table 2 Answers about the Diagnosis of Acromegaly Turkey (N = 280) Europe (N = 84) Asia and Africa (N = 32) P value N % N % N % Serum GH and IGF-1 levels are diagnostic tests for acromegaly Disagree/ No idea 179 63.9 59 70.2 22 68.8 Agree 101 36.1 25 29.8 10 31.3 0.525 Most of the patients with acromegaly have macroadenoma Disagree/ No idea 114 40.7 40 47.6 7 21.9 Agree 166 59.3 44 52.4 25 78.1 0.041 Acromegaly patients may have increased serum insulin and phosphorus levels Disagree/ No idea 109 38.9 38 45.2 12 37.5 Agree 171 61.1 46 54.8 20 62.5 0.556 Serum IGF-1 level is the single best test to be chosen in patients suspected to have acromegaly Disagree/ No idea 100 35.7 53 63.1 17 53.1 Agree 180 64.3 31 36.9 15 46.9 < 0.001 Oral glucose tolerance testing has no role in the diagnosis of acromegaly Agree/ No idea 127 45.4 36 42.9 22 68.8 Disagree 153 54.6 48 57.1 10 31.3 0.031 Asymptomatic patients with pituitary macroadenoma may have acromegaly Disagree/ No idea 102 36.4 45 53.6 0 0 Agree 178 63.6 39 46.4 32 100 < 0.001 Chi-square test Table 3 shows the comparison of the answers about the comorbidities seen with acromegaly. Colon cancer incidence is increased in acromegaly patients. The rate of primary care physicians who answered correctly to this question was higher in Asian/African (53.1%) physicians, and lower in European (17%) physicians (p < 0.001). Although most of the Turkish ( 97.1%) and European (96.4%) primary care physicians knew that acromegaly patients may have cardiomegaly and hypertension, 87.5% of Asian/African physicians answered correctly to this question (p = 0.025). Goiter incidence is increased in acromegaly patients. This comorbidity was better known by Asian/African primary care physicians (68.8%) compared to Turkish (47.9%) and European (41.7%) primary care physicians (p = 0.032). The presence of impaired glucose tolerance, infertility, sleep apnea, carpal tunnel syndrome, degenerative arthritis, and other pituitary hormone deficiencies are also the comorbidities seen in acromegaly patients. The knowledge of primary care physicians about these comorbidities was good enough. Table 3 Answers about the Comorbidities Turkey (N = 280) Europe (N = 84) Asia and Africa (N = 32) P value N % N % N % Patients with acromegaly may have impaired glucose tolerance Disagree/ No idea 29 10.4 16 19 2 6.3 Agree 251 89.6 68 81 30 93.8 0.057 Acromegaly patients may have sleep apnea Disagree/ No idea 51 18.2 23 27.4 8 25 Agree 229 81.8 61 72.6 24 75 0.157 Colon cancer incidence is increased in patients with acromegaly Disagree/ No idea 165 58.9 72 85.7 15 46.9 Agree 115 41.1 12 14.3 17 53.1 < 0.001 Acromegaly patients may have carpal tunnel syndrome Disagree/ No idea 54 19.3 25 29.8 7 21.9 Agree 226 80.7 59 70.2 25 78.1 0.124 Degenerative arthritis is not expected in acromegaly patients Agree/ No idea 83 29.6 25 29.8 13 40.6 Disagree 197 70.4 59 70.2 19 59.4 0.435 Acromegaly patients may have cardiomegaly and hypertension Disagree/ No idea 8 2.9 3 3.6 4 12.5 Agree 272 97.1 81 96.4 28 87.5 0.025 Goiter incidence is increased in acromegaly patients Disagree/ No idea 146 52.1 49 58.3 10 31.3 Agree 134 47.9 35 41.7 22 68.8 0.032 Acromegaly patients may have infertility Disagree/ No idea 57 20.4 10 11.9 5 15.6 Agree 223 79.6 74 88.1 27 84.4 0.196 Acromegaly patients may have hypothyroidism Agree/ No idea 258 92.1 82 97.6 30 93.8 Disagree 22 7.9 2 2.4 2 6.3 0.206 Psychiatric disorders are common findings in acromegaly patients Disagree/ No idea 122 43.6 33 39.3 12 37.5 Agree 158 56.4 51 60.7 20 62.5 0.671 Acromegaly patients may have hyperthyroidism Disagree/ No idea 166 59.3 46 54.8 12 37.5 Agree 114 40.7 38 45.2 20 62.5 0.058 Acromegaly patients may have other pituitary hormone deficiencies Disagree/ No idea 44 15.7 23 27.4 6 18.8 Agree 236 84.3 61 72.6 26 81.3 0.054 Chi-square test Table 4 shows the knowledge of primary care physicians about the treatment and prognosis of acromegaly. The mortality rate is increased in acromegaly, and the knowledge of primary care physicians about the prognosis was good enough. Surgery is the treatment of choice in acromegaly. Only 18.6% of Turkish and 13% of European primary care physicians answered correctly to this question. The rate of correct answers to this question was higher among Asian/African primary care physicians (59.4%) and the difference was statistically significant (p = 0.003). Most of the primary care physicians agreed that they would consult the patients suspected of acromegaly with an endocrinologist. Table 4 Answers about the Treatment and Prognosis of Acromegaly Turkey (N = 280) Europe (N = 84) Asia and Africa (N = 32) P value N % N % N % Surgery is the treatment of choice in acromegaly patients Disagree/ No idea 228 81.4 58 69 19 59.4 Agree 52 18.6 26 31 13 40.6 0.003 Mortality rate is increased in acromegaly patients Disagree/ No idea 48 17.1 13 15.5 10 31.3 Agree 232 82.9 71 84.5 22 68.8 0.115 I will consult the patients suspected of acromegaly with endocrinology Disagree/ No idea 12 4.3 3 3.6 2 6.3 Agree 268 95.7 81 96.4 30 93.8 0.817 Chi-square test Discussion Since acromegaly is a disease with a high mortality and morbidity rate, early diagnosis is crucial. The role of primary care physicians, who are responsible for primary and secondary preventive medicine services, is very important at this point. This study aimed to explore the thorough knowledge of primary care physicians from various nations about acromegaly. Although full participation from every country was not possible, primary care physicians from various countries could be reached, albeit in small numbers. Many different studies have shown that patients with acromegaly are diagnosed approximately 5–10 years after the onset of their complaints [ 9 – 11 ]. The uncertainty in the period until diagnosis creates anxiety in patients. Frequently, patients consult family physicians, gastroenterologists, gynecologists, orthopedists, endocrinologists, neurosurgeons, cardiologists, ophthalmologists, pulmonologists, ear-nose-throat diseases, and dentists for their undifferentiated complaints until the correct diagnosis is made [ 12 , 13 ]. It has been determined that this situation creates distrust in the healthcare system. In interviews with acromegaly patients in the USA, patients stated that primary care physicians must be better educated about acromegaly and that endocrinologists and primary care physicians should work together [ 12 ]. Primary health care is normally the point of the first medical contact within the health care system. Most of the studies showed that patients most often consult family physicians before acromegaly is diagnosed, but the diagnosis of acromegaly is most often made by endocrinologists [ 13 – 15 ]. On the other hand, Reid et al. demonstrated that half of the patients were diagnosed by primary care physicians [ 9 ]. In the study of Zarool-Hassan et al., most of the patients were in contact with general practitioners (GPs) and/or dentists before diagnosis and endocrinologists had the highest diagnosis rate, followed by GPs [ 13 ]. When women and men are compared; It has been found that women are diagnosed later, have more diverse symptoms, and consult more physicians until they are diagnosed [ 10 , 14 ]. It is estimated that most cases of acromegaly remain undiagnosed. It has been determined that the prevalence of acromegaly patients in primary health care is much higher than it is predicted [ 16 , 17 ]. In their study, Schneider et al. aimed to assess the prevalence of acromegaly in primary care by screening for elevated IGF-1 levels and found a high prevalence of undiagnosed acromegaly in their study population [ 16 ]. As a result of a study conducted in Latin America, it was recommended to identify target groups and perform screening for early diagnosis and treatment of acromegaly [ 18 ]. New diagnostic tools in the diagnosis of acromegaly Clinical scoring systems and artificial intelligence programs are being developed to assist physicians in the diagnosis of acromegaly. A two-question survey was prepared for use in primary healthcare institutions, asking whether shoe size and ring size have increased [ 17 ]. The 14-point ACROSCORE (symptom/sign scoring tool for acromegaly) system was created for the clinical diagnosis of acromegaly [ 11 ]. SAGIT (signs and symptoms (S), associated comorbidities (A), GH levels (G), IGF-1 levels (I), Tumor profile (T)) is a program developed by endocrinologists to help make acromegaly diagnosis, course, and treatment decisions. It includes signs and symptoms, associated comorbidities, growth hormone and IGF-1 levels, and tumor profile [ 19 ]. ACRODAT ( ACROmegaly Disease Activity Tool) is a program created to determine disease activity in acromegaly. IGF-1 level, tumor status, presence of comorbidities, symptoms, and quality of life are the five parameters used [ 20 ]. Artificial intelligence programs that can diagnose acromegaly using patients' photographs have been developed in various countries. These programs are superior to physicians in detecting acromegaly. It has been stated that the widespread use of artificial intelligence may increase the diagnosis rate of acromegaly [ 21 , 22 ]. Strengths and limitations To our knowledge, this is the first study measuring the knowledge and attitudes of primary care physicians from different countries about acromegaly. The limitation of our study is that the number of participants from other countries could not be obtained as much as from Turkey. Although attempts were made to reach out to primary care physicians through various social media groups, it was very challenging to recruit participants from other countries. The strengths of our study are that it reveals what primary care physicians know and do not know about the clinical manifestations, diagnosis, comorbidities, morbidity, and treatment of acromegaly. Primary care physicians know the facial and acral findings of acromegaly, but their knowledge about the possibility of visceromegaly and galactorrhea in these patients is poor. The majority of primary care physicians didn’t know that most acromegaly patients have macroadenoma and that serum IGF-1 level is the single best test to be chosen in patients suspected to have acromegaly. Primary care physicians also had a lack of knowledge about the comorbidities of acromegaly. The most significant of these were the increased risk of colon cancer and the incidence of goiter in patients with acromegaly. Our most striking finding is that most of the primary care physicians didn’t know that surgery is the treatment of choice in acromegaly patients. The most important strength of our study is that we have revealed the knowledge gaps of primary care physicians in every aspect of acromegaly. Conclusion The slow onset of symptoms, the fact that physical changes occur over a long period and cannot be easily noticed by the patient and their relatives, the fact that patients consult specialist physicians in different branches for different complaints, and the fact that physicians do not consider the diagnosis of acromegaly delay the diagnosis. During this period, complications and their severity increase, and patients continue to consult different physicians. Although technology has developed over the years, it has been determined that there is no significant difference in the time from the onset of complaints to diagnosis and the tumor size at diagnosis in the last 25 years. Although clinical scoring systems and artificial intelligence programs have been developed to assist physicians, the knowledge and attitude of physicians are the most important factors in diagnosing acromegaly. Early diagnosis of acromegaly, which causes many complications in patients, psychosocial problems, increased risk of mortality, and economic burden on the healthcare system, is very important. Treatment should be started as early as possible to prevent permanent effects. The role of primary care physicians is very important in the early diagnosis of acromegaly. Therefore, their knowledge about acromegaly should be increased through workshops, seminars, and subject-focused courses. Abbreviations IGF-1: Insulin-like growth factor-1 GH: Growth Hormone GP: General Practitioner SAGIT: signs and symptoms (S), associated comorbidities (A), GH levels (G), IGF-1 levels (I), Tumor profile (T) ACRODAT: ACROmegaly Disease Activity Tool ACROSCORE: symptom/sign scoring tool for acromegaly Declarations Acknowledgments: We would like to thank all primary care physicians who participated in our survey. Author contributions: Conceptualization: P.K., A.K.F., C.S., H.M.O.; statistical analysis: G.C.; investigation (conducting the surveys): A.K.F., E.U.D.; methodology: A.K.F., P.K., C.S., H.M.O.; project administration: A.K.F., E.U.D.; supervision: A.K.F., N.T.S.; writing—original draft: A.K.F.; writing—review and editing: N.T.S., G.C. Funding: We declare that we received no funding nor financial support/grants by any institutional, private, or corporate entity. Data availability: The datasets generated and/or analysed during the current project are not publicly available due to privacy and ethical restrictions but are available from the corresponding author on reasonable request. Ethics approval and consent to participate: This study was conducted according to the Declaration of Helsinki. All physicians who participated in the study face-to-face signed a written informed consent before participating. Those who participated through a Google form approved the informed consent which was added to the questionnaire. The Clinical Research Ethics Committee of Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty (approval date and number 21.10.2020-139312), approved the study Consent for publication: All authors have read and agreed to the published version of the manuscript. Competing interests: The authors declare no competing interests. References Ershadinia, N, Tritos NA. Diagnosis and treatment of acromegaly: an update. Mayo Clinic Proc. February 2022;97(2):333-346. https://doi.org/10.1016/j.mayocp.2021.11.007 Fleseriu M, Langlois F, Lim DST, Varlamov EV, Melmed S. Acromegaly: pathogenesis, diagnosis, and management. Lancet Diabetes Endocrinol. 2022 Nov;10(11):804-826. https://doi.org/10.1016/S2213-8587(22)00244-3 Lavrentaki A, Paluzzi A, Wass JAH, Karavitaki N. Epidemiology of acromegaly: review of population studies. Pituitary. 2017;20:4–9.https://doi.org/10.1007/s11102-016-0754-x Dhaneshwar S, Shandily S, Tiwari V. Growth Hormone Excess: Implications and Management. Endocr Metab Immune Disord Drug Targets. 2023;23(6):748-763.https://doi.org/10.2174/1871530322666221012155533 Chanson P, Salenave S. Acromegaly. Orphanet Journal of Rare Diseases. 2008;3:17.https://doi.org/10.1186/1750-1172-3-17 Hannah-Shmouni F, Trivellin G, Stratakis CA. Genetics of Gigantism and Acromegaly. Growth Horm IGF Res. (2016); 30-31: 37–41.https://doi.org/10.1016/j.ghir.2016.08.002 Abreu A, Tovar AP, Castellanos R, Valenzuela A, Giraldo CMG, Pinedo AC, et al. Challenges in the diagnosis and management of acromegaly: a focus on comorbidities. Pituitary. 2016;19(4):448–457.https://doi.org/10.1007/s11102-016-0725-2 Katznelson L, Laws ER Jr, Melmed S, Molitch ME, Murad MH, Utz A, et al. Acromegaly: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014;99(11):3933–3951.https://doi.org/10.1210/jc.2014-2700 Reid TJ, Post KD, Bruce JN, Nabi Kanibir M, Reyes-Vidal CM, Freda PU. Features at diagnosis of 324 patients with acromegaly did not change from 1981 to 2006: acromegaly remains under-recognized and under-diagnosed. Clin Endocrinol. 2010;72(2):203–208.DOI: 10.1111/j.1365-2265.2009.03626.x Petrossians P, Daly AF, Natchev E, Maione L, Blijdorp K et al. Acromegaly at diagnosis in 3173 patients from the Liege Acromegaly Survey (LAS) Database. Endocrine-Related Cancer. 2017 Oct;24(10):505-518. https://doi.org/ 10.1530/ERC-17-0253 Brue T, Castinetti F. The risks of overlooking the diagnosis of secreting pituitary adenomas. Orphanet Journal of Rare Diseases. 2016;11(1):135.DOI: 10.1186/s13023-016-0516-x Gurel MH, Bruening PR, Rhodes C, Lomax KG. Patient Perspectives on the impact of acromegaly: results from individual and group interviews. Patient Preference and Adherence 2014;8:53-62.https://doi.org/10.2147/PPA.S56740 Zarool-Hassan R, Conaglen HM, Conaglen JV, Elston MS. Symptoms and signs of acromegaly: an ongoing need to raise awareness among healthcare practitioners. Journal of Primary Health Care. 2016;8(2):157-163.DOI: 10.1071/HC15033 Kreitschmann-Andermahr I, Siegel S, Kleist B et al. Diagnosis and management of acromegaly: the patient’s perspective. Pituitary 2016;19:268–276.https://doi.org/10.1007/s11102-015-0702-1 Caron P, Brue T, Raverot G et al. Signs and symptoms of acromegaly at diagnosis: the physician’s and the patient’s perspectives in the ACRO-POLIS study. Endocrine 2019;63:120–129.https://doi.org/10.1007/s12020-018-1764-4 Schneider HJ, Sievers C, Saller B, Wittchen HU, Stalla GK. High prevalence of biochemical acromegaly in primary care patients with elevated IGF-1 levels. Clin Endocrinol. 2008;69(3):432–435.https://doi.org/10.1111/j.1365-2265.2008.03221.x Rosario PW, Calsolari MR. Screening for acromegaly by application of a simple questionnaire evaluating the enlargement of extremities in adult patients seen at primary health care units. Pituitary 2012;15: 179–183.https://doi.org/10.1007/s11102-011-0302-7 Danilowicz K, Fainstein Day P, Manavela MP et al. Implementing a screening program for acromegaly in Latin America: necessity versus feasibility. Pituitary 2016;19: 370-374.https://doi.org/10.1007/s11102-016-0714-5 Giustina A, Bevan JS, Bronstein MD et al. SAGIT: clinician-reported outcome instrument for managing acromegaly in clinical practice—development and results from a pilot study. Pituitary (2016) 19:39–49. DOI:10.1007/s11102-015-0681-2 Lely AJ, Gomez R, Pleil A et al. Development of ACRODAT®, a new software medical device to assess disease activity in patients with acromegaly. Pituitary (2017) 20:692–70.DOI 10.1007/s11102-017-0835-5 Kong X, Gong S, Su Ld, Howard N, Kong Y. Automatic Detection of Acromegaly From Facial Photographs Using Machine Learning Methods. EBioMedicine 27 (2018) 94–102.https://doi.org/10.1016/j.ebiom.2017.12.015 Schneider HJ, Kosilek RP, Günther M et al. Automatic Face Classification of Acromegaly. J Clin Endocrinol Metab, (2011), 96(7):2074 –2080.https://doi.org/10.1210/jc.2011-0237 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Dec, 2024 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 06 May, 2024 Submission checks completed at journal 03 May, 2024 Editor assigned by journal 03 May, 2024 First submitted to journal 30 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4351785","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":299097560,"identity":"12cd14a1-926c-4002-95a7-54016636f4a1","order_by":0,"name":"Aysen Kutan Fenercioglu","email":"data:image/png;base64,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","orcid":"","institution":"Istanbul University Cerrahpasa","correspondingAuthor":true,"prefix":"","firstName":"Aysen","middleName":"Kutan","lastName":"Fenercioglu","suffix":""},{"id":299097561,"identity":"857c0cf7-959a-4502-a908-b360427dc32e","order_by":1,"name":"Ebru Unur Demircan","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Ebru","middleName":"Unur","lastName":"Demircan","suffix":""},{"id":299097562,"identity":"4cccf308-85fc-4870-b79d-98056a2d7527","order_by":2,"name":"Gunay Can","email":"","orcid":"","institution":"Istanbul University Cerrahpasa","correspondingAuthor":false,"prefix":"","firstName":"Gunay","middleName":"","lastName":"Can","suffix":""},{"id":299097563,"identity":"258a3fa8-464a-4aa4-9bcb-2c96a2063c85","order_by":3,"name":"Cem Sulu","email":"","orcid":"","institution":"Istanbul University Cerrahpasa","correspondingAuthor":false,"prefix":"","firstName":"Cem","middleName":"","lastName":"Sulu","suffix":""},{"id":299097564,"identity":"4b604ead-1aaa-4fdb-820b-633589776cf7","order_by":4,"name":"Nurver Turfaner Sipahioglu","email":"","orcid":"","institution":"Istanbul University Cerrahpasa","correspondingAuthor":false,"prefix":"","firstName":"Nurver","middleName":"Turfaner","lastName":"Sipahioglu","suffix":""},{"id":299097565,"identity":"6db37867-70b6-4265-bb05-30700a33471b","order_by":5,"name":"Hande Mefkure Ozkaya","email":"","orcid":"","institution":"Istanbul University Cerrahpasa","correspondingAuthor":false,"prefix":"","firstName":"Hande","middleName":"Mefkure","lastName":"Ozkaya","suffix":""},{"id":299097566,"identity":"e5889fb7-6443-4519-ac3a-bd12417ff01b","order_by":6,"name":"Pinar Kadioglu","email":"","orcid":"","institution":"Istanbul University Cerrahpasa","correspondingAuthor":false,"prefix":"","firstName":"Pinar","middleName":"","lastName":"Kadioglu","suffix":""}],"badges":[],"createdAt":"2024-04-30 23:55:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4351785/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4351785/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-024-02692-y","type":"published","date":"2024-12-30T15:57:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73093240,"identity":"979bfe32-48f0-4f98-ad94-7751deed44a9","added_by":"auto","created_at":"2025-01-06 16:11:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1528829,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4351785/v1/5f196549-236d-4703-93ed-34f206c54ef2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The knowledge and attitudes of primary care physicians about acromegaly: a survey study with multinational participation","fulltext":[{"header":"Background","content":"\u003cp\u003eAcromegaly is a rare, endocrinological disease caused by chronic excessive secretion of growth hormone and insulin-like growth factor-1 (IGF-1) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Due to long-term exposure of tissues to growth hormone and IGF-1, many comorbidities such as cardiovascular, respiratory, metabolic, musculoskeletal, neurological, and neoplastic diseases may accompany [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In a review of studies, the prevalence of acromegaly ranged between 2.8 and 13.7 cases per 100,000 people and the annual incidence ranged between 0.2 and 1.1 cases per 100,000 people. The median age at diagnosis is in the fifth decade of life with a median diagnostic delay of 4.5\u0026ndash;5 years [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Acromegaly is a disease with a high morbidity and mortality rate. Diagnosis on time reduces the mortality rate of patients and improves their quality of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost acromegaly patients have pituitary macroadenoma and 60% of pituitary adenomas are pure somatotroph adenomas that secrete only growth hormone. Pituitary adenomas that secrete growth hormone together with prolactin are seen in 25% of cases. Adenomas that secrete TSH or ACTH along with growth hormone and carcinomas that secrete growth hormone are rare. Acromegaly is not observed in silent somatotroph adenomas that do not secrete growth hormone. Hypothalamic tumors that secrete Growth Hormone Releasing Hormone (GHRH) and pancreatic or bronchial carcinoid tumors may cause acromegaly by causing excessive secretion of growth hormone [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Multiple Endocrine Neoplasia type 1 and type 4, McCune-Albright syndrome, Carney complex, familial isolated pituitary adenoma, familial succinate dehydrogenase gene defects, and X-linked acrogigantism are different familial causes of acromegaly [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDue to the growth in soft tissues and bones, enlargement of the hands and feet and thickening of the fingers are observed in acromegaly patients. The patient's shoes and rings may become too small for him. Changes that occur on the face include prominence in the forehead, chin, and cheekbones, thickening of the lips, coarsening of facial lines due to nose widening, and malocclusion. There may be a hoarseness in the voice due to hypertrophy in the sinuses and larynx. Macroglossia may be seen [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The frequency of carpal tunnel syndrome, degenerative arthritis, and vertebral fractures is increased in acromegaly. Myalgia and arthralgia are observed in 30\u0026ndash;70% of patients. Increased thickness and oiliness of the skin, increased sweating and acanthosis nigricans are skin findings. Generalized visceromegaly may occur [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAtherosclerosis, coronary artery disease, and cerebrovascular events may occur due to the chronic excessive secretion of growth hormone and IGF-1, endothelial dysfunction through increased endothelial proliferation, increased oxidative stress, and the impairment of oxidative defense mechanisms [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Hypertension is very common, seen in 20\u0026ndash;50% of patients, and its prevalence increases as the duration of the disease increases. Cardiomyopathy, arrhythmias, hypertrophy of the heart muscle, congestive heart failure, and heart valve diseases are other cardiovascular complications [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In addition, diabetes mellitus, insulin resistance, glucose intolerance, hyperlipidemia, hypothyroidism, and goiter are metabolic complications. Increased body fat mass and an increase in total mass may occur. Frequent headaches, sleep apnea, oligomenorrhea, and carpal tunnel syndrome are atypical clinical manifestations associated with acromegaly [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The Endocrine Society clinical practice guidelines suggest screening for acromegaly by measurement of IGF-I in patients with typical clinical manifestations, but also in those who lack the typical clinical picture [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFactors that delay the diagnosis of acromegaly are the slow onset of acromegaly symptoms, the fact that physical findings occur over a long period and cannot be easily noticed by the patient and their relatives, the fact that patients consult different specialists for a wide range of complaints, and the fact that physicians do not consider the diagnosis of acromegaly. During this delay period, complications and the mortality rate increase [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although clinical scoring systems and artificial intelligence programs have been developed over the years to assist physicians, the knowledge and attitudes of physicians are still the most important factors in diagnosing acromegaly. In the context of a comprehensive approach and specific problem-solving skills, the role of primary care physicians is crucial for diagnosing acromegaly for this wide range of clinical manifestations. This study aims to determine the knowledge and attitudes of primary care physicians about acromegaly in different countries of the world.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and study population\u003c/h2\u003e \u003cp\u003eThis cross-sectional descriptive study was conducted between December 2020 and November 2023 by applying a survey to a total of 396 primary care physicians from various nations. Data from 280 primary care physicians from Turkey, 84 from European countries, 28 from Asian countries, and 4 from Africa were obtained by this survey. The European physicians who participated in the study were from Germany, Netherlands, Romania, England, North Macedonia, Serbia, France, Sweden, Slovenia, Portugal, Spain, Belgium, Ireland, and Croatia. The Asian physicians who participated in the study were from Pakistan, Malaysia, Georgia, Israel, and Malta. The African physicians who participated in the study were from Nigeria.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eThe survey consisted of 33 questions prepared by A.K.F., P.K., C.S., and H.M.O. The survey was prepared in both English and Turkish. Twelve of the questions were related to the clinical manifestations of acromegaly, six of them were about the diagnosis of acromegaly, twelve of them were related to the comorbidities associated with acromegaly, one question was about the treatment and two questions were about the prognosis of acromegaly. Respondents were asked to respond \u0026ldquo;agree\u0026rdquo; or \u0026ldquo;disagree/have no idea\u0026rdquo; to the questions.\u003c/p\u003e \u003cp\u003eMostly, the survey was administered via Google Forms sent to social media groups of primary care physicians. Some of the surveys were applied face-to-face during primary care physicians' meetings and congresses. The face-to-face survey was administered by A.K.F. The whole survey took 15 minutes to complete.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData about acromegaly knowledge and attitudes of Turkish physicians, European physicians, Asian, and African physicians were evaluated using the Chi-square test in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e,\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. P-values less than 0.05 were considered statistically significant. Data were entered and analyzed using SPSS for Windows version 16.0 (SPSS Inc; Chicago, IL, USA).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e This study was conducted according to the Declaration of Helsinki. All physicians who participated in the study face-to-face signed a written informed consent before participating. Those who participated through a Google form approved the informed consent which was added to the questionnaire. The Clinical Research Ethics Committee of Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty (approval date and number 21.10.2020\u0026ndash;139312), approved the study.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOut of 396 physicians who participated in the study, 280 were from Turkey, 84 were from Europe, and 32 were from Asia and Africa. The comparison of the answers to the questions was made between these three groups in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the comparison of the knowledge of primary care physicians about clinical manifestations of acromegaly. There wasn\u0026rsquo;t any statistical significance in questions related to the visual findings of acromegaly and the majority of the physicians answered correctly to this question. The questions about the acral findings, excessive sweating, and generalized visceromegaly in acromegaly revealed statistical significance between the groups. The presence of acral findings in acromegaly was better known by Turkish physicians (96.8%) compared to Asian/African (84.4%) and European (84.5%) physicians (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Although the majority of Asian/African physicians (81,3%) knew that patients complaining of excessive sweating may have acromegaly, only half of the Turkish and European physicians answered correctly to this question. (p\u0026thinsp;=\u0026thinsp;0.009). The presence of generalized visceromegaly in acromegaly was also better known by Asian/African physicians compared to Turkish and European physicians (78.1% vs 62.1% and 48.8%) (p\u0026thinsp;=\u0026thinsp;0.01). Although the majority of the primary care physicians answered correctly to the question \u0026ldquo;Old photographs can be informative in patients suspected to have acromegaly\u0026rdquo;, the rate of correct answers to this question was higher in Turkish and Asian/African groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Galactorrhea is a finding that can be seen in acromegaly and half of the Turkish and Asian/African physicians disagreed with the misleading question about galactorrhea. There was a statistical significance in the comparison of the groups in this question (p\u0026thinsp;=\u0026thinsp;0.01). Snoring in an underweight patient can be suggestive of acromegaly. This clinical finding was better known by Asian/African physicians (65%) compared to Turkish (28.6%) and European (44%) physicians (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnswers about the Clinical Manifestations of Acromegaly\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTurkey\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;280)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eEurope\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eAsia and Africa\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI will consider the diagnosis of acromegaly in patients admitted with acral findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e271\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e96.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e84.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatients with coarse facial features may have acromegaly disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e266\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.435\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatients complaining of excessive sweating may have acromegaly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e26\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e81.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients may suffer from peripheral edema\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e53.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOld photographs can be informative in patients suspected to have acromegaly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e275\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e98.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e89.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e32\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients may present with headache\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e90.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.174\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMenstrual irregularity can be found in acromegaly patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e93.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients may have generalized visceromegaly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e78.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGalactorrhea is not seen in patients with acromegaly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e156\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e55.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e53.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.049\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients do not have gynecomastia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e62.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e37.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.063\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients may present with visual problems\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e76.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e90.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSnoring in an underweight patient can be suggestive of acromegaly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e21\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e65.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eChi-square test\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the comparison of the knowledge of the primary care physicians about the diagnosis of acromegaly. The diagnosis of acromegaly is mainly made by serum GH and IGF-1 levels and demonstration of pituitary adenoma by radiological imaging. Only 36.1% of Turkish physicians, 29.8% of European physicians, and 31.3% of Asian/African physicians knew that serum GH and IGF-1 levels are diagnostic tests for acromegaly. Although 64.3% of Turkish physicians knew that serum IGF-1 level is the single best test to be chosen in patients suspected to have acromegaly, the rate of the correct answers to this question was low in European (36.9%) and Asian/African (46.9%) physicians (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The rate of physicians who knew that the diagnosis of acromegaly should be made by demonstration of macroadenoma was higher in Asia/African (78.1%) compared to Turkish (59.3%) and European (52.4%) physicians (p\u0026thinsp;=\u0026thinsp;0.041). Still, 100% of Asian/African physicians knew that asymptomatic patients with pituitary macroadenoma may have acromegaly. There was a statistical significance when this rate was compared with the rates of Turkish (63.6%) and European (46.4%) physicians (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients with acromegaly may have impaired glucose tolerance. Therefore, oral glucose tolerance testing is used in the diagnosis of acromegaly. The rate of physicians who answered correctly to the misleading question was higher among European physicians (57.1%) compared to Turkish (54.6%) and Asian/African (31.3%) physicians (p\u0026thinsp;=\u0026thinsp;0.031).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnswers about the Diagnosis of Acromegaly\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTurkey\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;280)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eEurope\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eAsia and Africa\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum GH and IGF-1 levels are diagnostic tests for acromegaly\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e70.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e68.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.525\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMost of the patients with acromegaly have macroadenoma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e47.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e52.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e25\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e78.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.041\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients may have increased serum insulin and phosphorus levels\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e45.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e37.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e54.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e62.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.556\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSerum IGF-1 level is the single best test to be chosen in patients suspected to have acromegaly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e63.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e53.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e180\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOral glucose tolerance testing has no role in the diagnosis of acromegaly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e68.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e153\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e54.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e48\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e57.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.031\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAsymptomatic patients with pituitary macroadenoma may have acromegaly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e53.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e46.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e32\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eChi-square test\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the comparison of the answers about the comorbidities seen with acromegaly. Colon cancer incidence is increased in acromegaly patients. The rate of primary care physicians who answered correctly to this question was higher in Asian/African (53.1%) physicians, and lower in European (17%) physicians (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Although most of the Turkish ( 97.1%) and European (96.4%) primary care physicians knew that acromegaly patients may have cardiomegaly and hypertension, 87.5% of Asian/African physicians answered correctly to this question (p\u0026thinsp;=\u0026thinsp;0.025). Goiter incidence is increased in acromegaly patients. This comorbidity was better known by Asian/African primary care physicians (68.8%) compared to Turkish (47.9%) and European (41.7%) primary care physicians (p\u0026thinsp;=\u0026thinsp;0.032). The presence of impaired glucose tolerance, infertility, sleep apnea, carpal tunnel syndrome, degenerative arthritis, and other pituitary hormone deficiencies are also the comorbidities seen in acromegaly patients. The knowledge of primary care physicians about these comorbidities was good enough.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnswers about the Comorbidities\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTurkey\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;280)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eEurope\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eAsia and Africa\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients with acromegaly may have impaired glucose tolerance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e93.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients may have sleep apnea\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eColon cancer incidence is increased in patients with acromegaly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e115\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e41.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e53.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients may have carpal tunnel syndrome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e78.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDegenerative arthritis is not expected in acromegaly patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e59.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.435\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients may have cardiomegaly and hypertension\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e272\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e97.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e81\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e96.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e87.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGoiter incidence is increased in acromegaly patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e22\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e68.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.032\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients may have infertility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e84.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.196\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients may have hypothyroidism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e92.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e93.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePsychiatric disorders are common findings in acromegaly patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e37.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e62.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.671\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients may have hyperthyroidism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e37.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e62.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcromegaly patients may have other pituitary hormone deficiencies\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e81.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eChi-square test\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the knowledge of primary care physicians about the treatment and prognosis of acromegaly. The mortality rate is increased in acromegaly, and the knowledge of primary care physicians about the prognosis was good enough. Surgery is the treatment of choice in acromegaly. Only 18.6% of Turkish and 13% of European primary care physicians answered correctly to this question. The rate of correct answers to this question was higher among Asian/African primary care physicians (59.4%) and the difference was statistically significant (p\u0026thinsp;=\u0026thinsp;0.003). Most of the primary care physicians agreed that they would consult the patients suspected of acromegaly with an endocrinologist.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnswers about the Treatment and Prognosis of Acromegaly\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTurkey\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;280)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eEurope\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eAsia and Africa\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery is the treatment of choice in acromegaly patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e59.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e13\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e40.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMortality rate is increased in acromegaly patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e68.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eI will consult the patients suspected of acromegaly with endocrinology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree/ No idea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e93.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.817\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eChi-square test\u003c/h2\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSince acromegaly is a disease with a high mortality and morbidity rate, early diagnosis is crucial. The role of primary care physicians, who are responsible for primary and secondary preventive medicine services, is very important at this point. This study aimed to explore the thorough knowledge of primary care physicians from various nations about acromegaly. Although full participation from every country was not possible, primary care physicians from various countries could be reached, albeit in small numbers.\u003c/p\u003e \u003cp\u003eMany different studies have shown that patients with acromegaly are diagnosed approximately 5\u0026ndash;10 years after the onset of their complaints [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The uncertainty in the period until diagnosis creates anxiety in patients. Frequently, patients consult family physicians, gastroenterologists, gynecologists, orthopedists, endocrinologists, neurosurgeons, cardiologists, ophthalmologists, pulmonologists, ear-nose-throat diseases, and dentists for their undifferentiated complaints until the correct diagnosis is made [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It has been determined that this situation creates distrust in the healthcare system. In interviews with acromegaly patients in the USA, patients stated that primary care physicians must be better educated about acromegaly and that endocrinologists and primary care physicians should work together [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrimary health care is normally the point of the first medical contact within the health care system. Most of the studies showed that patients most often consult family physicians before acromegaly is diagnosed, but the diagnosis of acromegaly is most often made by endocrinologists [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. On the other hand, Reid et al. demonstrated that half of the patients were diagnosed by primary care physicians [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In the study of Zarool-Hassan et al., most of the patients were in contact with general practitioners (GPs) and/or dentists before diagnosis and endocrinologists had the highest diagnosis rate, followed by GPs [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. When women and men are compared; It has been found that women are diagnosed later, have more diverse symptoms, and consult more physicians until they are diagnosed [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is estimated that most cases of acromegaly remain undiagnosed. It has been determined that the prevalence of acromegaly patients in primary health care is much higher than it is predicted [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In their study, Schneider et al. aimed to assess the prevalence of acromegaly in primary care by screening for elevated IGF-1 levels and found a high prevalence of undiagnosed acromegaly in their study population [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. As a result of a study conducted in Latin America, it was recommended to identify target groups and perform screening for early diagnosis and treatment of acromegaly [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eNew diagnostic tools in the diagnosis of acromegaly\u003c/h2\u003e \u003cp\u003eClinical scoring systems and artificial intelligence programs are being developed to assist physicians in the diagnosis of acromegaly. A two-question survey was prepared for use in primary healthcare institutions, asking whether shoe size and ring size have increased [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The 14-point ACROSCORE (symptom/sign scoring tool for acromegaly) system was created for the clinical diagnosis of acromegaly [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. SAGIT (signs and symptoms (S), associated comorbidities (A), GH levels (G), IGF-1 levels (I), Tumor profile (T)) is a program developed by endocrinologists to help make acromegaly diagnosis, course, and treatment decisions. It includes signs and symptoms, associated comorbidities, growth hormone and IGF-1 levels, and tumor profile [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. ACRODAT ( ACROmegaly Disease Activity Tool) is a program created to determine disease activity in acromegaly. IGF-1 level, tumor status, presence of comorbidities, symptoms, and quality of life are the five parameters used [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Artificial intelligence programs that can diagnose acromegaly using patients' photographs have been developed in various countries. These programs are superior to physicians in detecting acromegaly. It has been stated that the widespread use of artificial intelligence may increase the diagnosis rate of acromegaly [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eTo our knowledge, this is the first study measuring the knowledge and attitudes of primary care physicians from different countries about acromegaly. The limitation of our study is that the number of participants from other countries could not be obtained as much as from Turkey. Although attempts were made to reach out to primary care physicians through various social media groups, it was very challenging to recruit participants from other countries. The strengths of our study are that it reveals what primary care physicians know and do not know about the clinical manifestations, diagnosis, comorbidities, morbidity, and treatment of acromegaly. Primary care physicians know the facial and acral findings of acromegaly, but their knowledge about the possibility of visceromegaly and galactorrhea in these patients is poor. The majority of primary care physicians didn\u0026rsquo;t know that most acromegaly patients have macroadenoma and that serum IGF-1 level is the single best test to be chosen in patients suspected to have acromegaly. Primary care physicians also had a lack of knowledge about the comorbidities of acromegaly. The most significant of these were the increased risk of colon cancer and the incidence of goiter in patients with acromegaly. Our most striking finding is that most of the primary care physicians didn\u0026rsquo;t know that surgery is the treatment of choice in acromegaly patients. The most important strength of our study is that we have revealed the knowledge gaps of primary care physicians in every aspect of acromegaly.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe slow onset of symptoms, the fact that physical changes occur over a long period and cannot be easily noticed by the patient and their relatives, the fact that patients consult specialist physicians in different branches for different complaints, and the fact that physicians do not consider the diagnosis of acromegaly delay the diagnosis. During this period, complications and their severity increase, and patients continue to consult different physicians. Although technology has developed over the years, it has been determined that there is no significant difference in the time from the onset of complaints to diagnosis and the tumor size at diagnosis in the last 25 years. Although clinical scoring systems and artificial intelligence programs have been developed to assist physicians, the knowledge and attitude of physicians are the most important factors in diagnosing acromegaly. Early diagnosis of acromegaly, which causes many complications in patients, psychosocial problems, increased risk of mortality, and economic burden on the healthcare system, is very important. Treatment should be started as early as possible to prevent permanent effects. The role of primary care physicians is very important in the early diagnosis of acromegaly. Therefore, their knowledge about acromegaly should be increased through workshops, seminars, and subject-focused courses.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eIGF-1: Insulin-like growth factor-1\u003c/p\u003e\n\u003cp\u003eGH: Growth Hormone\u003c/p\u003e\n\u003cp\u003eGP: General Practitioner\u003c/p\u003e\n\u003cp\u003eSAGIT: signs and symptoms (S), associated comorbidities (A), GH levels (G), IGF-1 levels (I), Tumor profile (T)\u003c/p\u003e\n\u003cp\u003eACRODAT: ACROmegaly Disease Activity Tool\u003c/p\u003e\n\u003cp\u003eACROSCORE: symptom/sign scoring tool for acromegaly\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e We would like to thank all primary care physicians who participated in our survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions: \u0026nbsp;\u003c/strong\u003eConceptualization: P.K., A.K.F., C.S., H.M.O.; statistical analysis: G.C.; investigation (conducting the surveys): A.K.F., E.U.D.; methodology: A.K.F., P.K., C.S., H.M.O.; project administration: A.K.F., E.U.D.; supervision: A.K.F., N.T.S.; writing\u0026mdash;original draft: A.K.F.; writing\u0026mdash;review and editing: N.T.S., G.C.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eWe declare that we received no funding nor financial support/grants by any institutional, private, or corporate entity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eThe datasets generated and/or analysed during the current project are not publicly available due to privacy and ethical restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was conducted according to the Declaration of Helsinki. \u0026nbsp;All physicians who participated in the study face-to-face signed a written informed consent before participating. Those who participated through a Google form approved the informed consent which was added to the questionnaire. The Clinical Research Ethics Committee of Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty (approval date and number 21.10.2020-139312), approved the study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eAll authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eErshadinia, N, Tritos NA. Diagnosis and treatment of acromegaly: an update. Mayo Clinic Proc. February 2022;97(2):333-346. https://doi.org/10.1016/j.mayocp.2021.11.007\u003c/li\u003e\n\u003cli\u003eFleseriu M, Langlois F, Lim DST, Varlamov EV, Melmed S. Acromegaly: pathogenesis, diagnosis, and management. Lancet Diabetes Endocrinol. 2022 Nov;10(11):804-826. https://doi.org/10.1016/S2213-8587(22)00244-3\u003c/li\u003e\n\u003cli\u003eLavrentaki A, Paluzzi A, Wass JAH, Karavitaki N. Epidemiology of acromegaly: review of population studies. Pituitary. 2017;20:4\u0026ndash;9.https://doi.org/10.1007/s11102-016-0754-x\u003c/li\u003e\n\u003cli\u003eDhaneshwar S, Shandily S, Tiwari V. Growth Hormone Excess: Implications and Management. Endocr Metab Immune Disord Drug Targets. 2023;23(6):748-763.https://doi.org/10.2174/1871530322666221012155533\u003c/li\u003e\n\u003cli\u003eChanson P, Salenave S. Acromegaly. Orphanet Journal of Rare Diseases. 2008;3:17.https://doi.org/10.1186/1750-1172-3-17\u003c/li\u003e\n\u003cli\u003eHannah-Shmouni F, Trivellin G, Stratakis CA. Genetics of Gigantism and Acromegaly. Growth Horm IGF Res. (2016); 30-31: 37\u0026ndash;41.https://doi.org/10.1016/j.ghir.2016.08.002\u003c/li\u003e\n\u003cli\u003eAbreu A, Tovar AP, Castellanos R, Valenzuela A, Giraldo CMG, Pinedo AC, et al. Challenges in the diagnosis and management of acromegaly: a focus on comorbidities. Pituitary. 2016;19(4):448\u0026ndash;457.https://doi.org/10.1007/s11102-016-0725-2\u003c/li\u003e\n\u003cli\u003eKatznelson L, Laws ER Jr, Melmed S, Molitch ME, Murad MH, Utz A, et al. Acromegaly: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014;99(11):3933\u0026ndash;3951.https://doi.org/10.1210/jc.2014-2700\u003c/li\u003e\n\u003cli\u003eReid TJ, Post KD, Bruce JN, Nabi Kanibir M, Reyes-Vidal CM, Freda PU. Features at diagnosis of 324 patients with acromegaly did not change from 1981 to 2006: acromegaly remains under-recognized and under-diagnosed. Clin Endocrinol. 2010;72(2):203\u0026ndash;208.DOI: 10.1111/j.1365-2265.2009.03626.x\u003c/li\u003e\n\u003cli\u003ePetrossians P, Daly AF, Natchev E, Maione L, Blijdorp K et al. Acromegaly at diagnosis in 3173 patients from the Liege Acromegaly Survey (LAS) Database. Endocrine-Related Cancer. 2017 Oct;24(10):505-518.\u003cu\u003ehttps://doi.org/\u003c/u\u003e10.1530/ERC-17-0253\u003c/li\u003e\n\u003cli\u003eBrue T, Castinetti F. The risks of overlooking the diagnosis of secreting pituitary adenomas. Orphanet Journal of Rare Diseases. 2016;11(1):135.DOI: 10.1186/s13023-016-0516-x\u003c/li\u003e\n\u003cli\u003eGurel MH, Bruening PR, Rhodes C, Lomax KG. Patient Perspectives on the impact of acromegaly: results from individual and group interviews. Patient Preference and Adherence 2014;8:53-62.https://doi.org/10.2147/PPA.S56740\u003c/li\u003e\n\u003cli\u003eZarool-Hassan R, Conaglen HM, Conaglen JV, Elston MS. Symptoms and signs of acromegaly: an ongoing need to raise awareness among healthcare practitioners. Journal of Primary Health Care. 2016;8(2):157-163.DOI: 10.1071/HC15033\u003c/li\u003e\n\u003cli\u003eKreitschmann-Andermahr I, Siegel S, Kleist B et al. Diagnosis and management of acromegaly: the patient\u0026rsquo;s perspective. Pituitary 2016;19:268\u0026ndash;276.https://doi.org/10.1007/s11102-015-0702-1\u003c/li\u003e\n\u003cli\u003eCaron P, Brue T, Raverot G et al. Signs and symptoms of acromegaly at diagnosis: the physician\u0026rsquo;s and the patient\u0026rsquo;s perspectives in the ACRO-POLIS study. Endocrine 2019;63:120\u0026ndash;129.https://doi.org/10.1007/s12020-018-1764-4\u003c/li\u003e\n\u003cli\u003eSchneider HJ, Sievers C, Saller B, Wittchen HU, Stalla GK. High prevalence of biochemical acromegaly in primary care patients with elevated IGF-1 levels. Clin Endocrinol. 2008;69(3):432\u0026ndash;435.https://doi.org/10.1111/j.1365-2265.2008.03221.x\u003c/li\u003e\n\u003cli\u003eRosario PW, Calsolari MR. Screening for acromegaly by application of a simple questionnaire evaluating the enlargement of extremities in adult patients seen at primary health care units. Pituitary 2012;15: 179\u0026ndash;183.https://doi.org/10.1007/s11102-011-0302-7\u003c/li\u003e\n\u003cli\u003eDanilowicz K, Fainstein Day P, Manavela MP et al. Implementing a screening program for acromegaly in Latin America: necessity versus feasibility. Pituitary 2016;19: 370-374.https://doi.org/10.1007/s11102-016-0714-5\u003c/li\u003e\n\u003cli\u003eGiustina A, Bevan JS, Bronstein MD et al. SAGIT: clinician-reported outcome instrument for managing acromegaly in clinical practice\u0026mdash;development and results from a pilot study. Pituitary (2016) 19:39\u0026ndash;49. DOI:10.1007/s11102-015-0681-2\u003c/li\u003e\n\u003cli\u003eLely AJ, Gomez R, Pleil A et al. Development of ACRODAT\u0026reg;, a new software medical device to assess disease activity in patients with acromegaly. Pituitary (2017) 20:692\u0026ndash;70.DOI 10.1007/s11102-017-0835-5\u003c/li\u003e\n\u003cli\u003eKong X, Gong S, Su Ld, Howard N, Kong Y. Automatic Detection of Acromegaly From Facial Photographs Using Machine Learning Methods. EBioMedicine 27 (2018) 94\u0026ndash;102.https://doi.org/10.1016/j.ebiom.2017.12.015\u003c/li\u003e\n\u003cli\u003eSchneider HJ, Kosilek RP, G\u0026uuml;nther M et al. Automatic Face Classification of Acromegaly. J Clin Endocrinol Metab, (2011), 96(7):2074 \u0026ndash;2080.https://doi.org/10.1210/jc.2011-0237\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acromegaly, Primary care, knowledge, attitudes","lastPublishedDoi":"10.21203/rs.3.rs-4351785/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4351785/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eAcromegaly is a disease with a high morbidity and mortality rate. The role of primary care physicians is very important in the early diagnosis of acromegaly. This study aims to determine the knowledge and attitudes of primary care physicians about acromegaly in different countries of the world.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The survey, consisting of 33 questions prepared in English and Turkish, was applied to a total of 396 primary care physicians, 280 of whom were from Turkey, 84 from European countries, 28 from Asian countries, and 4 from Nigeria. Mostly, the survey was administered via Google Forms sent to social media groups of primary care physicians. Some of the surveys were applied face-to-face. The survey included 12 questions about the clinical manifestations, six questions about the diagnosis, 12 questions about the comorbidities, one question about the treatment, and two questions about the prognosis of acromegaly. Data about acromegaly knowledge and attitudes of physicians were evaluated using the Chi-square test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The presence of acral findings in acromegaly was better known by Turkish physicians (96.8%) compared to Asian/African (84.4%) and European (84.5%) physicians (p\u0026lt;0.001). The presence of generalized visceromegaly and excessive sweating in acromegaly was better known by Asian/African physicians (p=0.01 and p=0.009). “Old photographs can be informative in patients suspected to have acromegaly”, the rate of correct answers to this question was higher in Turkish and Asian/African groups (p\u0026lt;0.001). Only 36.1% of Turkish physicians, 29.8% of European physicians, and 31.3% of Asian/African physicians knew that serum GH and IGF-1 levels were diagnostic tests for acromegaly. Although 64.3% of Turkish physicians knew that serum IGF-1 level was the single best test to be chosen in patients suspected to have acromegaly, the rate of the correct answers to this question was low in European (36.9%) and Asian/African (46.9%) physicians (p\u0026lt;0.001). Only 18.6% of Turkish and 13% of European physicians knew that surgery was the treatment of choice in acromegaly. The rate of correct answers to this question was higher in Asian/African physicians (59.4%) (p=0.003).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The knowledge of primary care physicians about acromegaly should be increased through workshops, seminars, and subject-focused courses.\u003c/p\u003e","manuscriptTitle":"The knowledge and attitudes of primary care physicians about acromegaly: a survey study with multinational participation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-09 11:58:54","doi":"10.21203/rs.3.rs-4351785/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-06T07:03:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-03T08:59:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-03T08:59:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2024-04-30T23:54:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ae266967-bb60-46fd-96ec-c38459925dc7","owner":[],"postedDate":"May 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-06T15:59:44+00:00","versionOfRecord":{"articleIdentity":"rs-4351785","link":"https://doi.org/10.1186/s12875-024-02692-y","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2024-12-30 15:57:08","publishedOnDateReadable":"December 30th, 2024"},"versionCreatedAt":"2024-05-09 11:58:54","video":"","vorDoi":"10.1186/s12875-024-02692-y","vorDoiUrl":"https://doi.org/10.1186/s12875-024-02692-y","workflowStages":[]},"version":"v1","identity":"rs-4351785","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4351785","identity":"rs-4351785","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}