L’inibizione tireotropinica da metformina non si associa a segni cardiologici di ipertiroidismo subclinico

Recenti dati di letteratura hanno evidenziato come metformina determini una riduzione/soppressione dei livelli sierici di tireotro- pina (TSH), simulando un ipertiroidismo subclinico il cui signifi- cato clinico rimane a oggi ancora assai controverso. Sebbene l’ipertiroidismo subclinico sia nella maggioranza dei casi una condizione clinica asintomatica, è altrettanto noto come esso si associ a un aumentato rischio di aritmie (più frequentemente la fibrillazione atriale) e ad alterazioni morfo-funzionali cardiache determinando un aumento di morbilità e mortalità cardiovasco- lare. Scopo del presente studio è stato quello di valutare retrospetti- vamente le alterazioni di differenti indici elettrocardiografici in pazienti diabetici eutiroidei che, dopo aver intrapreso terapia con metformina, hanno sviluppato riduzione/soppressione dei valori di TSH comparando i dati con quelli ottenuti in pazienti con iper- tiroidismo subclinico secondario a patologie tiroidee o a terapia soppressiva con L-tiroxina. I parametri elettrocardiografici (frequenza cardiaca, durata del- l’onda P, indice di dispersione dell’onda P, QT max, QT min, indice di dispersione dell’intervallo QT) sono stati valutati in 23 pazienti diabetici in terapia con metformina prima e dopo 6 mesi dall’instaurarsi della soppressione del TSH e in 31 con- trolli con ipertiroidismo subclinico. Nessuna modifica significa- tiva è stata osservata tra i parametri elettrocardiografici rilevati prima e dopo la riduzione del TSH. Al contrario, significative dif- ferenze nella durata dell’onda P (102,9 ± 7,4 vs 92,1 ± 5,8 ms, p < 0,001), dell’indice di dispersione dell’onda P (13,1 ± 3,4 vs 7,1 ± 3,5 ms, p < 0,001), del QT max (399 ± 18 vs 388 ± 16 ms, p = 0,024), del QT min (341 ± 14 vs 350 ± 17 ms, p = 0,038) e di quello dell’intervallo QT (49,9 ± 9,6 vs 30,9 ± 9,2 ms, p < 0,001) sono state rilevate tra i controlli con iperti- roidismo subclinico e il gruppo di pazienti diabetici con valori ridotti/soppressi di TSH. I risultati del nostro studio evidenzierebbero come l’effetto di riduzione/soppressione del TSH osservato in alcuni pazienti dia- betici in terapia con metformina non si associ a marker periferi- ci cardiaci da eccesso di ormoni tiroidei. L’alterazione del profilo tiroideo metformina-indotto sembrerebbe non indicativo di iper- tiroidismo subclinico, suggerendo quindi che non sussiste la necessità di sottoporre a stretti controlli della funzione tiroidea i pazienti diabetici in terapia con metformin

A Case of Concurrent Riedel's, Hashimoto's and Acute Suppurative Thyroiditis

Riedel's thyroiditis (RT) is a rare form of infiltrative and inflammatory disease of the thyroid, first described by Bernard Riedel in 1896. The concurrent presence of RT and other thyroid diseases has been reported, but, the association of RT with Hashimoto's thyroiditis and acute thyroiditis has not yet been reported. We present a case of concurrent Riedel's, Hashimoto's and acute thyroiditis that occurred in a 45-year-old patient

Oral liquid L-thyroxine (L-t4) may be better absorbed compared to L-T4 tablets following bariatric surgery.

Drug malabsorption is a potential concern after bariatric surgery. We present four case reports of hypothyroid patients who were well replaced with thyroxine tablets to euthyroid thyrotropin (TSH) levels prior to Roux-en-Y gastric bypass surgery. These patients developed elevated TSH levels after the surgery, the TSH responded reversibly to switching from treatment with oral tablets to a liquid formulation

Fine needle cytology of complex thyroid nodules.

OBJECTIVE: To evaluate whether a preliminary aspiration (ASP) of the cystic component and/or using spinal needles in complex thyroid nodules (CTN) could improve the adequacy of cytological sampling. METHODS: Between January 2004 and December 2006, 386 consecutive patients with CTN were enrolled in this prospective investigation. Ultrasound (US) fine needle aspiration cytology (FNAC) of the solid component of the nodule (one nodule per patient) was performed using two different 25 gauge needles, with (Yale Spinal, YS) or without (Neolus, NS) a stylet, in alternate sequence on consecutive patients. In addition, a subgroup of patients presenting larger cystic component (approximately 50%) was submitted to total aspiration of the cystic component (ASP+) or not submitted (ASP-) before US-FNAC, in alternate sequence within each needle type group. All the samplings were performed by a single endocrinologist. RESULTS: Adequate specimens were observed in 163 (84.5%) and 183 (94.8%) nodules investigated by NS and YS respectively. Sampling with the stylet needle was associated with an overall significant reduction of non-diagnostic specimens (15.5% vs 5.2% by NS and YS respectively, P < 0.001). The favourable result obtained with YS was independent from preliminary aspiration of the cystic component (ASP+: 14.8% vs 5.7% by NS and YS; ASP-: 16.2% vs 4.8%, not significant). A logistic regression analysis, taking into account nodule size and presence of intranodal vascularity at eco-colour evaluation of the solid component, confirmed that needle type was the only significant predictor of successful sampling (odds ratio 3.6 (95% confidence interval 1.7-7.6), P < 0.001). CONCLUSIONS: Our data show that adopting stylet needles to perform FNAC in CTN may significantly improve the percentage of adequate sampling. On the other hand, preliminary aspiration of CTN with large cystic component does not add any advantage

Modified percutaneous ethanol injection of parathyroid adenoma in primary hyperparathyroidism.

Surgery is the treatment of choice for symptomatic primary hyperparathyroidism; unlikely few patients do not meet established surgical criteria or have comorbid conditions that prohibit surgery. In these subjects, medical therapy alone offers little hope for a sustained long normocalcemic period. However percutaneous ethanol injection (PEI) may represent an alternative therapeutic procedure. It is currently in use for the treatment of secondary or tertiary hyperparathyroidism, however, few studies or case reports suggest it for the treatment of primary hyperparathyroidism. Moreover, little information is available about the long-term follow-up, where incomplete necrosis or the spreading of ethanol in the surrounding tissues is often reported. We believe that many of the side effects could be correlated to procedure itself. Taking these experiences into account, we have reasoned that in order to limit these side effects, we had to modify the standard PEI procedure. We reported this preliminary experience describing our modified PEI procedure

Prognostic value of thyrotropin receptor antibodies (TRAb) in Graves' disease: a 120 months prospective study

In most trials, at least 30-60% of patients with Graves' disease treated with antithyroid drugs relapse within 2 years after therapy withdrawal. At present, there are no prognostic parameters available early in treatment to indicate patients likely to achieve long-term remission. Because thyrotropin receptor autoantibodies (TRAb) are specific for Graves' disease, we evaluated the ability of their levels and of their rate of change to predict long-term prognosis. In our study 216 consecutive patients with newly diagnosed Graves' disease started a therapy with methimazole. Patients were treated until they achieved euthyroidism and TRAb were measured at 6-month intervals throughout a follow up of 120 months. Our study demonstrated that at the onset of hyperthyroidism patients' age, sex, fT4 levels and goiter size had no prognostic value in predicting long-term prognosis (respectively p = 0.79; p = 0.98; p = 0.83; p = 0.89). On the contrary, at the time of diagnosis TRAb titer was a good predictor of the final outcome (p<0.001); a titer equal to (or) more than 46.5 UI/L could identify patients who had never achieved long-term remission with a sensitivity of 52% and a specificity of 78%. Also fall rate of TRAb at 6 months of follow up and after therapy withdrawal were useful to predict the final outcome (p<0.001). At 6 months of follow up the time of therapy withdrawal, a decrease of TRAb lower than 52.3% or even its increase could identify patients who had never achieved permanent remission with a sensitivity of 55% and a specificity of 79.1%. No single parameter among TRAb, satisfactory identified a sub-set of patients who achieved long remission. Accordingly to our data, the best result in predicting long term remission is probably given by the presence of at least one of the two features evaluated at 6 months (TRAb titer and/or percentage of TRAb fall rate), with a sensitivity of 63% and specificity of 88%. TRAb titers evaluated both at the onset of hyperthyroidism that at 6 months of therapy or their rate of fall at 6 months and at ATD withdrawal are predictors of outcome. However, the presence of at least one, between titers of TRAb or their rate of fall at six months, resulted to be the best predictor of remission with the higher sensitivity and specificity

TSH-Lowering Effect of Metformin in Type 2 Diabetic Patients: Differences between euthyroid, untreated hypothyroid, and euthyroid on L-T4 therapy patients

OBJECTIVE: To assess the interplay between metformin treatment and thyroid function in type 2 diabetic patients. RESEARCH DESIGN AND METHODS: The acute and long-term effects of metformin on thyroid axis hormones were assessed in diabetic patients with primary hypothyroidism who were either untreated or treated with levothyroxine (L-T4), as well as in diabetic patients with normal thyroid function. RESULTS: No acute changes were found in 11 patients with treated hypothyroidism. After 1 year of metformin administration, a significant thyrotropin (TSH) decrease (P < 0.001) was observed in diabetic subjects with hypothyroidism who were either treated (n = 29; from 2.37 +/- 1.17 to 1.41 +/- 1.21 mIU/l) or untreated (n = 18; 4.5 +/- 0.37 vs. 2.93 +/- 1.48) with L-T4, but not in 54 euthyroid subjects. No significant change in free T4 (FT4) was observed in any group. CONCLUSIONS: Metformin administration influences TSH without change of FT4 in patients with type 2 diabetes and concomitant hypothyroidism. The need for reevaluation of thyroid function in these patients within 6-12 months after starting metformin is indicated

Evaluation of a large set of patients with Autoimmune Polyglandular Syndrome from a single reference centre in context of different classifications

Purpose: To characterize patients with APS and to propose a new approach for their follow-up. Query ID="Q1" Text="Please check the given names and familynames." Methods: Monocentric observational retrospective study enrolling patients referred to the Outpatients clinic of the Units of Endocrinology, Diabetology, Gastroenterology, Rheumatology and Clinical Immunology of our Hospital for Autoimmune diseases. Results: Among 9852 patients, 1174 (11.9%) [869 (73.9%) female] were diagnosed with APS. In 254 subjects, the diagnosis was made at first clinical evaluation (Group 1), all the other patients were diagnosed with a mean latency of 11.3 ± 10.6 years (Group 2). Group 1 and 2 were comparable for age at diagnosis (35.7 ± 16.3 vs. 40.4 ± 16.6 yrs, p =.698), but different in male/female ratio (81/173 vs 226/696, p =.019). In Group 2, 50% of patients developed the syndrome within 8 years of follow-up. A significant difference was found after subdividing the first clinical manifestation into the different outpatient clinic to which they referred (8.7 ± 8.0 vs. 13.4 ± 11.6 vs. 19.8 ± 8.7 vs. 7.4 ± 8.1 for endocrine, diabetic, rheumatologic, and gastroenterological diseases, respectively, p <.001). Conclusions: We described a large series of patients affected by APS according to splitters and lumpers. We propose a flowchart tailored for each specialist outpatient clinic taking care of the patients. Finally, we recommend regular reproductive system assessment due to the non-negligible risk of developing premature ovarian failure

Frailty and post-operative delirium influence on functional status in patients with hip fracture: the GIOG 2.0 study

Background: This study analyzes the effect of frailty and Post-Operative Delirium (POD) on the functional status at hospital discharge and at 4-month follow-up in patients with hip fracture (HF). Methods: Multicenter prospective observational study of older patients with HF admitted to 12 Italian Orthogeriatric centers (July 2019-August 2022). POD was assessed using the 4AT. A 26-item Frailty Index (FI) was created using data collected on admission. The outcome measures were Cumulated Ambulation Score (CAS) ≤ 2 at discharge and a telephone-administered CAS ≤ 2 after 4&nbsp;months. Poisson regression models were used to assess the effect of frailty and POD on outcomes. Results: 984 patients (median age 84&nbsp;years, IQR = 79–89) were recruited: 480 (48.7%) were frail at admission, 311 (31.6%) developed POD, and 158 (15.6%) had both frailty and POD. In a robust Poisson regression, frailty alone (Relative Risk, RR = 1.56, 95% Confidence Intervals, CI 1.19–2.04, p = 0.001) and its combination with POD (RR = 2.57, 95% CI 2.02–3.26, p &lt; 0.001) were associated with poor functional status at discharge. At 4-month follow-up, the combination of frailty with POD (RR 3.65, 95% CI 1.85–7.2, p &lt; 0.001) increased the risk of poor outcome more than frailty alone (RR 2.38, 95% CI 1.21–4.66, p &lt; 0.001). Conclusions: POD development exacerbates the negative effect that frailty exerts on functional outcomes in HF patients