Value of repeated US-guided fine-needle aspiration (US-FNAB) in the follow-up of benign thyroid nodules: a real-life study based on the MoCyThy (Modena's Cytology of the Thyroid) DATABASE with a revision of the literature

PURPOSE

The utility of repeating ultrasound-guided fine-needle aspiration (US-FNAB) in the follow-up of benign (THY2) thyroid nodules is still debated. The aim of this study was to retrospectively investigate the diagnostic value of re-biopsy of thyroid nodules following an initially benign result.

METHODS

We retrospectively analyzed US-FNABs performed at the Unit of Endocrinology of Modena from 2006 to 2009. The firstly benign cytological result was compared with the cytological results of subsequent US-FNABs (2nd and/or 3rd) executed on the same nodule.

RESULTS

Among 10449 US-FNABs, 6270 (60%) received a THY2 cytological categorization. Of them, 278 (4.43%) underwent a subsequent US-FNAB: 86.7% maintained the same cytology, 32 (11.5%) changed to THY3 (indeterminate) and 5 (1.8%) to THY4 (suspicious of malignancy). Among the 24 nodules addressed to surgery, 9 (37%) were histologically malignant, with an overall miss rate of 3.2%. Male patients had higher risk of discordant results at subsequent US-FNAB (p = 0.005, OR:3.59, 95%CI:1.453-7.769) while dimensional increase above 5 mm was predictive of concordant benign cytology (p = 0.036, OR:0.249, 95%CI:0.068-0.915). Age, suspicious US characteristics, and distance between US-FNABs resulted not predictive.

CONCLUSIONS

Re-biopsy of benign nodules confirmed the benign nature in most cases. In case of discordant cytology, relocation in indeterminate category was the most common. The histological diagnosis of cancer occurred in one quarter of nodules surgically removed, with a low overall clinically significant miss rate. Thus, a small percentage of false negatives exists; males and subjects with US suspicious nodules should be carefully followed-up, considering case by case re-biopsy possibility.

COVID-19 lockdown negatively impacted on adherence to denosumab therapy: incidence of non-traumatic fractures and role of telemedicine

PURPOSE

Coronavirus disease (COVID-19) lockdowns have impacted on management of osteoporosis and the use of telemedicine is increasingly widespread albeit supported by little evidence so far. The aim of the study is to assess adherence to denosumab and incidence of non-traumatic fractures during the lockdown compared to the pre-COVID-19 year and to explore the effectiveness of telemedicine in the management of osteoporotic patients.

METHODS

Retrospective, longitudinal, single-center study on patients receiving subcutaneous denosumab therapy every 6 months. Each patient was scheduled to undergo 2 visits: one during the pre-COVID-19 period (March 2019-March 2020) and another visit during the lockdown period (March 2020-March 2021). Data on new fractures, adherence, risk factors for osteoporosis and the modality of visit (telemedicine or face-to-face) were collected.

RESULTS

The prevalence of non-adherent patients was higher during the lockdown (35 of 269 patients, 13.0%) than the pre-COVID-19 period (9 of 276 patients, 3.3%) (p < 0.0001). During the lockdown, the number of new non-traumatic fractures was higher than the pre-COVID-19 year (p < 0.0001): 10 patients out of 269 (3.7%) experienced a fragility fracture and 2 patients (0.7%) a probable rebound fracture during the lockdown period, whereas no patient had fragility/rebound fractures during the pre-COVID-19 period. No difference was found in the prevalence of non-adherence and new non-traumatic fractures comparing patients evaluated with tele-medicine to those evaluated with face-to-face visit.

CONCLUSION

Non-adherent patients and new non-traumatic fractures (including rebound fractures) were more prevalent during the lockdown in comparison to the pre-COVID-19 period, regardless of the modality of medical evaluation.

Long-Term Use of Temozolomide as Safe and Effective Therapy for an Aggressive Corticotroph Adenoma in a Very Old Patient

Background

Temozolomide (TMZ) is safe and effective in the treatment of aggressive pituitary adenomas (PAs). However, the optimal duration of TMZ therapy is still unknown. Moreover, data about administration of TMZ in elderly (≥65 years) people to treat aggressive PAs are scarce. We report the case of the oldest female patient undergoing the longest TMZ protocol described so far to treat an aggressive, initially silent corticotroph PA.

Case report

The patient initially underwent partial surgical removal of the PA. Subsequent treatment with cabergoline was applied, but it was unsuccessful in controlling the growth of the residual tumor. Pasireotide and external radiation also showed to be ineffective; therefore, treatment with TMZ was started at the standard dose of 200 mg/m²/day for 5 days every 4 weeks for a total of 47 cycles. At the time of treatment’s beginning, the patient was 83 years old. Radiological follow-up documented a progressive, remarkable reduction of the adenoma and the last imaging, after 39 cycles of TMZ, showed an intrasellar lesion with large areas of cystic degeneration. The patient also developed adrenal deficiency managed with glucocorticoid replacement. No major side effects were observed throughout the treatment, with exception of nausea, well controlled with anti-emetic medication. TMZ therapy was discontinued after 47 cycles; hormonal and imaging follow-up investigations documented sustained functional and dimensional response.

Conclusions

Our case supports the long-term use of TMZ, confirming its safety and efficacy also for elderly patients.

The Added Value of Operator's Judgement in Thyroid Nodule Ultrasound Classification Arising From Histologically Based Comparison of Different Risk Stratification Systems

Objective: Several ultrasound classifications for thyroid nodules were proposed but their accuracy is still debated, since mainly estimated on cytology and not on histology. The aim of this study was to test the diagnostic accuracy and the inter-classification agreement of AACE/ACE-AME, American Thyroid Association (ATA), British Thyroid Association (BTA), and Modena Ultrasound Thyroid Classification (MUT) that stratifies malignancy risk considering also the clinician subjective impression. Methods: A prospective study collecting thyroid nodule features at ultrasound and histological diagnosis was conducted. Ultrasound features were collected following a preformed checklist in candidates for surgery because of indeterminate, suspicious, or malignant cytology. All the nodules, besides the cytologically suspicious one, were blinded analyzed. MUT score was applied prospectively, and the others retrospectively. Sensitivity, specificity, diagnostic cut-off value, and accuracy of each classification were calculated. The overall agreement between classifications was tested by Bland-Altman, and agreement between single nodule analysis by different classifications by Weighted Cohen's Kappa. Results: In classifying a total of 457 nodules, MUT has the highest accuracy (AUC 0.808) and specificity (89%), followed by ATA and BTA, and finally by AACE/ACE-AME. ATA, BTA, and MUT are highly interchangeable. Considering agreement between single nodule analyses, ATA and BTA had the best (κ = 0.723); AACE/ACE-AME showed slight agreement with BTA (κ = 0.177) and MUT (κ = 0.183), and fair agreement with ATA (κ = 0.282); MUT had fair agreement with both ATA (κ = 0.291) and BTA (κ = 0.271). Conclusion: Classifications have an acceptable overall diagnostic accuracy, improved using a less rigid system that takes into consideration operator subjective impression.

MON-580 Diagnostic Accuracy of Different Thyroid Ultrasound Classification Systems and the Added Value of Operator Subjective Impression in Stratifying Nodule Risk

Background and aim. Several ultrasound (US) classifications for thyroid nodules have been proposed. Since most of them are hardly applicable in clinical practice, we set up the Modena US Thyroid Classification (MUT) that stratifies the risk of malignancy based on knowledge derived from scientific literature and on clinician subjective impression. The aim of the present study was to test the diagnostic accuracy of different thyroid US classification systems, AACE/ACE-AME, American Thyroid Association (ATA), British Thyroid Association (BTA), and MUT, and to evaluate inter-classification agreement. Methods. We prospectively enrolled 111 patients (33M, 78F; age 19-75) with indeterminate, suspicious or malignant cytology. All the patients underwent neck US before surgery and a score according to MUT was assigned: 1 not certainly nodular; 2 not suspect; 3 indeterminate; 4 suspect; 5 very suspect. Then, we retrospectively classified nodules according to AACE/ACE-AME, ATA and BTA. US pattern was related to hystology. Sensitivity, specificity, diagnostic cut-off value and accuracy of each classification were calculated. The overall agreement between classifications was quantified by Bland-Altman test. The agreement between single nodule analysis by different classifications was evaluated considering Weighted Cohen's Kappa. Results. Fifteen patients had uninodular and 96 multinodular goiter, for a total of 457 nodules. MUT has the highest accuracy (AUC 0.808) and specificity (89%), followed by ATA and BTA, and finally by AACE/ACE-AME. ATA and BTA are highly interchangeable and MUT is comparable to both of them. AACE/ACE-AME is the least interchangeable with all the other classifications. Considering agreement between single nodule analysis by different classifications, ATA and BTA had the best (k=0.723); AACE/ACE-AME showed slight agreement with BTA (k=0.177) and MUT (k=0.183), and fair agreement with ATA (k=0.282); MUT had fair agreement with both ATA (k=0.291) and BTA (k=0.271). Conclusions. Our findings bring out the limit in specificity of the current reference classifications, which improves when the subjective impression of the clinician is considered.

Pituitary growth hormone (GH) secretion is partially rescued in HIV-infected patients with GH deficiency (GHD) compared to hypopituitary patients

Biochemical growth hormone deficiency is prevalent among human immunodeficiency virus-infected patients, but if this condition is clinically relevant remains challenging. The aim is to prospectively compare the growth hormone deficiency/insulin-like growth factor-1 status of 71 human immunodeficiency virus-infected patients with impaired growth hormone response to growth hormone releasing hormone + Arginine with that of 65 hypopituitary patients affected by a true growth hormone deficiency secondary to pituitary disease. The main outcomes were: basal serum growth hormone, insulin-like growth factor-1, insulin-like growth factor binding protein 3, growth hormone peak and area under the curve after growth hormone response to growth hormone releasing hormone + Arginine test, body mass index, waist and hip circumference, and body composition by dual energy X-ray absorptiometry. Insulin-like growth factor-1 binding protein 3, basal growth hormone (p < 0.005), growth hormone peak and area under the curve after growth hormone response to growth hormone releasing hormone + Arginine, waist to hip ratio, insulin-like growth factor-1, fasting glucose, insulin, and triglycerides (p < 0.0001) were lower in hypopituitary than human immunodeficiency virus-infected patients. Total and trunk fat mass by dual energy X-ray absorptiometry were higher in hypopituitary than in human immunodeficiency virus-infected patients (p < 0.0001). In all the patients total body fat was associated with both growth hormone peak and area under the curve at stepwise linear regression analysis. The degree of growth hormone deficiency is more severe in hypopituitary than in human immunodeficiency virus-infected patients, suggesting that the function of growth hormone/insulin-like growth factor-1 axis is partially rescued in the latter thanks to a preserved pituitary secretory reserve. Data from the current study suggest that human immunodeficiency virus-infected patients with peak growth hormone < 9 mg/L may have partial growth hormone deficiency and clinicians should be cautious before prescribing recombinant human growth hormone replacement treatment to patients living with human immunodeficiency virus.

Gender differences in GH response to GHRH+ARG in lipodystrophic patients with HIV: a key role for body fat distribution

OBJECTIVE

Gender influence on GH secretion in human immunodeficiency virus (HIV)-infected patients is poorly known.

DESIGN AND METHODS

To determine the effect of gender, we compared GH response to GH-releasing hormone plus arginine (GHRH+Arg), and body composition in 103 men and 97 women with HIV and lipodystrophy. The main outcomes were IGF1, basal GH, GH peak and area under the curve (AUC) after GHRH+Arg, body composition, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT).

RESULTS

Men had lower GH peak and AUC than women (P<0.001). Of the study population, 21% of women and 37% of men had biochemical GH deficiency (GHD; GH peak <7.5 μg/l). VAT-to-SAT ratio was higher in men than in women with GHD (P<0.05). Unlike women, VAT, SAT, and trunk fat were greater in men with GHD than in men without GHD. IGF1 was significantly lower in women with GHD than in women without GHD, but not in men. At univariate analysis, BMI, trunk fat mass, VAT, and total adipose tissue were associated with GH peak and AUC in both sexes (P<0.05). BMI was the most significant predictive factor of GH peak, and AUC at multiregression analysis. Overall, abdominal fat had a less pronounced effect on GH in females than in males.

CONCLUSIONS

These data demonstrate that GH response to GHRH+Arg is significantly lower in HIV-infected males than females, resulting in a higher percentage of GHD in men. Adipose tissue distribution more than fat mass per se seems to account for GH gender differences and for the alteration of GH-IGF1 status in these patients.

Effect of Lourdes water on water pH

In samples of normal table water, the level of pH is significantly lower than that of reference samples, when an aliquot of water originating from the springs close to the sanctuary to the Virgin Mary at Lourdes at a final dilution rate of 1:400,000 parts has been added to the sample of water tested. The differences as compared to the reference waters, that is those samples to which the aliquot of Lourdes water were not added, were tested by analysis of the variance and were found to be highly significant. The measurements were conducted on approximately 600 samples. It was demonstrated that the phenomenon observed could not be attributed to chemical species present in the Lourdes water which can justify the lowering of the pH in relation to the dilution rate with which the work was performed.

Effect of the Lourdes water on "chlorinated water"

The present study demonstrated that the decay of chlorine concentration in samples of common water, additivated with free chlorine, is significantly slower if a certain amount of water taken from the Marian Sanctuary of Lourdes is added to the sample to be tested. The observed phenomenon is independent of the dilution ratio of the Lourdes water in spring water, that is, it practically identical both at low dilution (1:200) and at high dilutions (1:1 x 10(23)).

[Study of a population sample conducted using the bioenergy gold test]

Experiments carried out using the bioenergy gold test showed that a bioradiant subject working on water without touching, is able to modify the evolution of the gold colloid generated by chemical reaction in the treated water sample. To complete these researches, experiments were carried out on 50 pranotherapeutic practitioners and on 50 normal subjects. Statistical analysis shows that the results in normal subjects differ from those in the pranotherapeutic practitioners. These observations confirm that pranotherapeutists act physically on the water, modifying the structure of the liquid and the chemical gold test is able to reveal these changes.

Evaluation of reproterol's effectiveness in preventing exercise-induced bronchospasm in children

The authors have evaluated the effectiveness of the protection of a new beta 2-adrenergic compound, reproterol, against broncho-constriction induced by physical exercise in a group of individuals of paediatric age sensitive to broncho-stimulation. This study has been carried out comparing reproterol with salbutamol, using placebo as a control, following a randomized single-blind crossover trial. The provocation test has been performed following the instructions of the Italian Society of Paediatrics. The drugs have been administered in the oral liquid form at the dose of 0.28 mg/kg and 0.1 mg/kg of reproterol and salbutamol, respectively. The two substances have shown a similar preventive effectiveness in controlling exercise-induced asthma up to 2 hours from administration with reproterol having a stronger action at the beginning of the observation.

The effect of bile acids on liver alcohol dehydrogenase in different mammalian species

1. The effect of bile acids on the activity of liver alcohol dehydrogenase (L-ADH, EC 1.1.1.1) from different mammalian organisms is species dependent. 2. The kinetic behaviour of purified L-ADH from rat and rabbit liver in presence of deoxycholic acid and with ethanol as substrate shows two rather different patterns: for rabbit enzyme deoxycholic acid acts as a full competitive inhibitor, while for rat enzyme an activation effect is observed, with an increase of both Km and Vmax. Similar patterns are obtained with the steroid substrate 3 beta-hydroxy-5 beta-androstane-17one. 3. These results show that in some species, including man, L-ADH activity can be regulated by bile acids, that could control both ethanol oxidation and their own biosynthesis since L-ADH is involved in both metabolic pathways in liver cell.