Comparison of 2 fracture risk estimation processes in Alberta: a cross-sectional chart review.

BACKGROUND: In Canada, decisions regarding osteoporosis pharmacotherapy are based on estimated 10-year risk of osteoporotic fracture. We aimed to determine how frequently 2 common approaches (Canadian Association of Radiologists and Osteoporosis Canada [CAROC] tool and Fracture Risk Assessment Tool [FRAX]) produced different estimates and to seek possible explanations for differences. METHODS: We conducted a cross-sectional chart review at a tertiary osteoporosis centre (Dr. David Hanley Osteoporosis Centre in Calgary). Included patients were women referred for consideration of osteoporosis pharmacotherapy who attended a consultation between 2016 and 2019 and whose charts contained 10-year osteoporotic fracture risk estimates using both the CAROC tool (based on bone mineral density [BMD] results) and FRAX (based on BMD results and clinically assessed fracture risk factors). Risk estimates provided on BMD reports (calculated with CAROC) and generated through osteoporosis clinic consultation (calculated with FRAX, including BMD) were categorized as low (< 10.0%), moderate (10.0%-19.9%) or high (≥ 20.0%). Estimates were considered discordant when they placed the patient in different risk categories. RESULTS: Of 190 patients evaluated, 99 (52.1%) had discordant risk estimates. Although a similar proportion were considered high risk by BMD reports using the CAROC tool (17.9%) and clinic charts using FRAX (19.5%), the 2 methods identified different patients as being high risk. Around the crucial high-risk (20.0%) treatment threshold, discordance was present in 37 patients (19.5%, 95% confidence interval [CI] 14.5%-25.7%); discordance around the moderate-risk (10.0%) threshold was present in 69 (36.3%, 95% CI 29.5%-43.2%) patients. Disagreement regarding fracture history between BMD reports and clinic charts was observed in 19.8% of patients. INTERPRETATION: Fracture risk estimates on BMD reports (using the CAROC tool) and those calculated in the clinical setting (using FRAX) frequently result in different risk classification. Osteoporosis treatment decisions may differ in up to half of patients depending on which estimate is used, highlighting the need for a consistent and accurate assessment process for fracture risk.

An Update on Addison's Disease.

Addison's disease - the traditional term for primary adrenal insufficiency (PAI) - is defined as the clinical manifestation of chronic glucocorticoid- and/or mineralocorticoid deficiency due to failure of the adrenal cortex which may result in an adrenal crisis with potentially life-threatening consequences. Even though efficient and safe pharmaceutical preparations for the substitution of endogenous gluco- and mineralocorticoids are established in therapy, the mortality in patients with PAI is still increased and the health-related quality of life (HRQoL) is often reduced.PAI is a rare disease but recent data report an increasing prevalence. In addition to the common "classical" causes of PAI like autoimmune, infectious, neoplastic and genetic disorders, other iatrogenic conditions - mostly pharmacological side effects (e. g., adrenal haemorrhage associated with anticoagulants, drugs affecting glucocorticoid synthesis, action or metabolism and some of the novel anti-cancer checkpoint inhibitors) are contributing factors to this phenomenon.Due to the rarity of the disease and often non-specific symptoms at least in the early stages, PAI is frequently not considered resulting in a delayed diagnosis. Successful therapy is mainly based on adequate patient education as a cornerstone in the prevention and management of adrenal crisis. A focus of current research is in the development of pharmacokinetically optimized glucocorticoid preparations as well as regenerative therapies.

A Multi-institutional Comparison of Adrenal Venous Sampling in Patients with Primary Aldosteronism: Caution Advised if Successful Bilateral Adrenal Vein Sampling is Not Achieved.

INTRODUCTION: In patients with primary aldosteronism (PA), adrenal venous sampling (AVS) is recommended to differentiate between unilateral (UNI) or bilateral (BIL) adrenal disease. A recent study suggested that lateralization could be predicted, based on the ratio of aldosterone/cortisol levels (A/C) between the left adrenal vein (LAV) and inferior vena cava (IVC), with a 100% positive predictive value (PPV). This study aimed to validate those findings utilizing a larger, multi-institutional cohort. METHODS: A retrospective review was performed of patients with PA who underwent AVS from 2 tertiary-care institutions. Laterality was predicted by an A/C ratio of >3:1 between the dominant and non-dominant adrenal. AVS results were compared to LAV/IVC ratios utilizing the published criteria (Lt ≥ 5.5; Rt ≤ 0.5). RESULTS: Of 222 patients, 124 (57%) had UNI and 98 (43%) had BIL disease based on AVS. AVS and LAV/IVC findings were concordant for laterality in 141 (64%) patients (69 UNI, 72 BIL). Using only the LAV/IVC ratio, 54 (24%) patients with UNI disease on AVS who underwent successful surgery would have been assumed to have BAH unless AVS was repeated, and 24 (11%) patients with BIL disease on AVS may have been incorrectly offered surgery (PPV 70%). Based on median LAV/IVC ratios (left 5.26; right 0.31; BIL 2.84), no LAV/IVC ratio accurately predicted laterality. DISCUSSION: This multi-institutional study of patients with both UNI and BIL PA failed to validate the previously reported PPV of LAV/IVC ratio for lateralization. Caution should be used in interpreting incomplete AVS data to differentiate between UNI versus BIL disease and strong consideration given to repeat AVS prior to adrenalectomy.

Modification of the protocol for selective adrenal venous sampling results in both a significant increase in the accuracy and necessity of the procedure in the management of patients with primary hyperaldosteronism.

BACKGROUND: Adrenal venous sampling (AVS) is used in the work-up of primary hyperaldosteronism (PA) to distinguish unilateral PA from bilateral adrenal hyperplasia. In 2006, we reported that only 44% of AVS had biochemical evidence of bilateral adrenal vein cannulation (BAVC). Critical appraisal of our practice resulted in a protocol change. This study examined the impact of this new protocol on both the technical success rate and its influence on management of PA. METHODS: Since 2006, all patients with biochemically documented PA referred to either a single endocrine surgeon or endocrine specialist underwent AVS. Successful BAVC was defined as an adrenal vein to inferior vena cava/cortisol ratio of >3:1. Lateralization was defined as an aldosterone:cortisol ratio >3 times the unaffected side. RESULTS: Of the 86 AVS performed on 84 patients with PA, 82 had BAVC (95%). AVS altered the management in 26 of 84 (31%) patients. Despite clear unilateral findings on imaging in 45 patients, AVS demonstrated bilateral adrenal hyperplasia. in 10 and contralateral disease in 3. AVS confirmed unilateral PA in 5 patients with equivocal <1 cm nodules. In 4 of 25 patients with normal adrenal glands, AVS demonstrated lateralization. AVS demonstrated unilateral PA in 4 of 9 patients in whom imaging suggested bilateral adrenal hyperplasia. CONCLUSION: Our new AVS protocol resulted in a marked improvement in BAVC. AVS influenced management in a third of patients with PA. Surgical decision-making cannot be made solely on the basis of cross-sectional imaging.

Physical activity for men receiving androgen deprivation therapy for prostate cancer: benefits from a 16-week intervention.

GOALS OF WORK: Prostate cancer patients receiving androgen deprivation therapy (ADT) are vulnerable to a number of potentially debilitating side effects, which can significantly impact quality of life. The role of alternate therapies, such as physical activity (PA), in attenuating these side effects is largely understudied for such a large population. Thus, the purpose of this study was to investigate the effects of PA intervention for men receiving ADT on PA behavior, quality of life, and fitness measures. PATIENTS AND METHODS: One hundred participants were randomized into an intervention (n = 53) or a wait-list control group (n = 47), with 11 dropping out of the intervention group and 23 dropping out of the wait-list control group prior to post-testing. The intervention consisted of both an individually tailored home-based aerobic and light resistant training program and weekly group sessions. PA, quality of life, fitness, and physiological outcomes were assessed pre and post the 16-week intervention. RESULTS: Significant increases in PA, supported by changes in girth measures and blood pressure, support the beneficial impact of the intervention. Positive trends were also evident for depression and fatigue. However, due to the high dropout rate, these results must be interpreted with caution. CONCLUSIONS: PA effectively attenuates many of the side effects of ADT and should be recommended to prostate survivors as an alternate therapy. Determining the maintenance of this behavior change will be important for understanding how the long-term benefits of increased activity levels may alleviate the late effects of ADT.

131I-meta-iodobenzylguanidine in the management of metastatic midgut carcinoid tumors.

The management of metastatic neuroendocrine tumors incorporates multimodal therapy with surgery, biotherapy, and chemotherapy. Tumor-targeted therapies using radiolabeled octreotide and metaiodobenzylguanidine (mIBG) represent a novel treatment approach. The aim of this study was to evaluate the effectiveness of 131I-mIBG in the treatment of metastatic midgut carcinoid tumors. survival outcomes were assessed for patients treated at two regional cancer centers and then compared. One center used 131I-mIBG routinely in the management of metastatic carcinoid tumors (center A), and the other did not use this modality (center B). Only patients with histologically proven metastatic carcinoid tumor shown, or thought most likely, to be of midgut origin were included in the study. During the period 1980 to 2002, a series of 58 patients from center A with metastatic carcinoid tumor arising from the midgut underwent multimodality therapy with the addition of 131I-mIBG. Their median age was 64 years. The median dose of 131I-mIBG administered was 6751 MBq, and there was an average of 2.8 treatments per patient. During the same period, 58 patients with metastatic carcinoid were treated at center B with similar multimodality therapy without the use of 131I-mIBG therapy. Their median age was 65 years. Survivals at 3 and 5 years were 77% and 63%, respectively (95% CI 47-75), for group A. The 3- and 5-year survivals for group B were 56% and 47% (95% CI 34-59), respectively. The mean follow-up was 6.6 years for group A and 5.0 years for group B. Although retrospective in nature, this study suggests that the addition of 131I-mIBG therapy to the treatment protocol of patients with metastatic midgut carcinoid tumors prolongs survival.