Ectopic thyroid in EBUS: experience from a quality assurance programme.

A diagnostic challenge is presented: Distinguishing ectopic thyroid tissue from metastatic well-differentiated follicular carcinoma in cytological material. Two cases of thyroid tissue in mediastinal lymph nodes were sampled by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Later, the cases were presented in Labquality's nongynecological external quality scheme rounds in the years 2017, 2019, and 2020. The same case was presented two times, both in the 2017 and in the 2020 rounds. The results of the three rounds and the discussion of diagnostic pitfalls of ectopic thyroid tissue are presented. A total of 112 individual laboratories worldwide participated in the external quality assurance rounds with whole-slide scanned images and digital still images of alcohol-fixed Papanicolaou-stained cytospin specimens in the years 2017, 2019, and 2020. Fifty-three laboratories participated in both the 2017 (53 of 70, 75.71%) and the 2020 (53 of 85, 62.35%) rounds. The given Pap classes between rounds were compared. Twelve (12 of 53, 22.6%) of the laboratories gave the same Pap class value, whereas 32 (32 of 53, 60.4%) were in the range of ±1 class difference (Cohen's kappa -0.035, p < 0.637). When comparing the diagnoses, 21 (21 of 53, 39.6%) laboratories gave the same diagnosis in 2017 and in 2020 (Cohen's kappa 0.039, p < 0.625). Thirty-two of the laboratories gave the same diagnosis both in 2017 and in 2020 (Cohen's kappa 0.004, p < 0.979). Ten (10 of 53, 18.9%) laboratories changed their diagnose from malignant to benign, and 11 (11 of 53, 20.8%) changed their diagnose from benign to malignant between the 2017 and the 2020 rounds. In conclusions, the expert reference diagnosis was thyroid tissue in mediastinal lymph node. Thyroid tissue in mediastinal lymph node may be either of ectopic or of neoplastic origin. The diagnostic work-up should include cytomorphological, immunohistochemical, laboratory, and imaging results. If a neoplastic change is excluded, the benign category is the most feasible one. The quality assurance rounds showed a large variability in the given Pap classes. Mirroring the problematic issue both inter- and intralaboratory of such cases both in routine diagnostics and in the classification terminologies is requiring multidisciplinary evaluation approach in the diagnostics.

Cost-Effectiveness of Apixaban versus Other Direct Oral Anticoagulants and Warfarin in the Prevention of Thromboembolic Complications Among Finnish Patients with Non-Valvular Atrial Fibrillation.

PURPOSE: Direct oral anticoagulant (DOAC) use for the prevention of thromboembolic complications in patients with non-valvular atrial fibrillation (AF) has increased steadily in Finland. DOACs have been shown to be cost-effective in comparison to warfarin, but published evidence of relative cost-effectiveness between DOACs is still scarce and mostly based on indirect comparisons of clinical trial evidence. The aim of this study was to compare the cost-effectiveness of apixaban to dabigatran, rivaroxaban and warfarin in a Finnish setting using real-life evidence where available. PATIENTS AND METHODS: A lifetime Markov simulation model used previously in a published Finnish assessment comparing apixaban and warfarin was modified and updated with the relative effectiveness and safety data available from the real-world NAXOS-study and representative Finnish input data for patient characteristics, event risks, mortality, resource use, costs, and quality of life. Apixaban's cost-effectiveness was assessed from health care payer perspective (using 3% per year discount rate) based on incremental cost-effectiveness ratio (ICER, cost per quality-adjusted life year [QALY] gained), probability of cost-effectiveness (at willingness-to-pay [WTP] of 35,000 euros/QALY), and net monetary benefit (NMB). RESULTS: Apixaban increased the average modelled quality-adjusted life-expectancy and reduced the average total health care costs of AF patients when compared to warfarin (+0.14 QALYs, -3691 euros), dabigatran (+0.11 QALYs, -404 euros), and rivaroxaban (+0.03 QALYs, -43 euros). The resulting NMB of apixaban versus warfarin, dabigatran and rivaroxaban was 8723, 4168, and 1129 euros, respectively. The respective probabilities of apixaban being cost-effective against each comparator were 100%, 92.7%, and 64.0%. CONCLUSION: In this modelling study, apixaban dominated other anticoagulants in the Finnish real-life setting.