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.

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.

Concomitant medullary thyroid carcinoma with paraganglioma-like pattern and papillary thyroid carcinoma

SUMMARY

A 74-year-old man was referred to the Endocrinology Unit because of multinodular goiter. The dominant nodule (1.7 × 1.9 × 2.4 cm), at the medium-superior third of the left lobe, was inhomogeneously hypoechoic, with irregular margins, macrocalcifications and intranodular vascularization. Fine-needle aspiration biopsy (FNAB) was performed. The cytological diagnosis was TIR 2, benign, according to the 2013 Italian thyroid cytology classification system. Moderately high serum calcitonin (s-Ct) (61.5 pg/mL, n.r. 0-7.5) and normal CEA were detected. The Ct level in FNAB wash-out fluid (Ct-FNAB) was 1450 pg/mL. Based on s-Ct and Ct-FNAB levels, patient underwent total thyroidectomy. Macroscopically, a dominant circumscribed nodule of 2 ecm was described; the histological and immunohistochemical features identified medullary thyroid carcinoma (MTC) with paraganglioma (PG)-like pattern positive for Ct, CEA and chromogranin and negative for S-100 sustentacular cells (SC). Moreover, papillary carcinoma of 3 mm in the right lobe was also associated. No areas of hyperaccumulation of the tracer were documented at Ga68 PET/CT. No RET-proto-oncogene mutations were found. Post-surgery s-Ct levels were within normal range (4 pg/mL). Two years after thyroidectomy, the patient is still disease-free. We reported a case of sporadic and rare variant of MTC: this is the ninth described case of PG-like MTC. In this case, cytologically benign, the clinical suspicion arose from high Ct values at FNAB wash-out fluid. Even if clinical behavior of this variant seems indolent, additional studies are necessary to understand prognoses and predictive factors.

LEARNING POINTS

Several unusual histological variants of medullary thyroid carcinoma (MTC) have been described such as spindle cell, giant cell, clear cell, melanotic, squamous, angiosarcoma-like variants; even rarer is the paraganglioma (PG)-like pattern. We here describe a case of medullary PG-like thyroid carcinoma in a 74-year-old man. This is a rare histological variant of MTC hardly diagnosed by cytology, since immunohistochemical investigations are necessary. Measurement of calcitonin both in serum and in wash-out fluid from fine-needle aspiration could be an additional tool for an early and non-invasive identification of these variants.

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.

Aromatase expression in human peripheral blood leucocytes (PBLs) and in various tissues in primates: studies in elderly humans and cynomolgus monkeys

BACKGROUND

Previous analysis of aromatase gene and protein expression in peripheral blood leucocytes (PBLs), studied in children and adults, was extended to elderly subjects. In addition, we assessed whether aromatase expression in PBLs could be used as a parameter of aromatase expression in other tissues, using the cynomolgus monkey as model.

METHODS

Real-time PCR analysis of aromatase gene expression and protein evaluation by Western blot was performed in PBLs of human elderly subjects and in various tissues from cynomolgus monkeys.

RESULTS

No gender-related difference in CYP19A1 mRNA and protein expression in PBLs from human elderly women and men was found. In elderly male cynomolgus monkeys, CYP19A1 mRNA and protein were expressed in all cells and tissues analysed, with the lowest levels in PBLs but no clear-cut correlation with other tissues.

CONCLUSIONS

Aromatase expression in PBLs in elderly human subjects is not gender-related and cannot be a surrogate of aromatase expression for other tissues.