The TNAPP web-based algorithm improves thyroid nodule management in clinical practice: A retrospective validation study

BackgroundThe detection of thyroid nodules has been increasing over time, resulting in an extensive use of fine-needle aspiration (FNA) and cytology. Tailored methods are required to improve the management of thyroid nodules, including algorithms and web-based tools.Study aimsTo assess the performance of the Thyroid Nodule App (TNAPP), a web-based, readily modifiable, interactive algorithmic tool, in improving the management of thyroid nodules.MethodsOne hundred twelve consecutive patients with 188 thyroid nodules who underwent FNA from January to December 2016 and thyroid surgery were retrospectively evaluated. Neck ultrasound images were collected from a thyroid nodule registry and re-examined to extract data to run TNAPP. Each nodule was evaluated for ultrasonographic risk and suitability for FNA. The sensitivity, specificity, positive and negative predictive values, and overall accuracy of TNAPP were calculated and compared to the diagnostic performance of the other two algorithms by the American Association of Clinical Endocrinology/American College of Endocrinology/Associazione Medici Endocrinologi (AACE/ACE/AME), which it was derived from the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS).ResultsTNAPP performed better in terms of sensitivity (>80%) and negative predictive value (68%) with an overall accuracy of 50.5%, which was similar to that found with the AACE/ACE/AME algorithm. TNAPP displayed a slightly better performance than AACE/ACE/AME and ACR TI-RADS algorithms in selectively discriminating unnecessary FNA for nodules with benign cytology (TIR 2 - Bethesda class II: TNAPP 32% vs. AACE/ACE/AME 31% vs. ACR TI-RADS 29%). The TNAPP reduced the number of missed diagnoses of thyroid nodules with suspicious and highly suspicious cytology (TIR 4 + TIR 5 - Bethesda classes V + VI: TNAPP 18% vs. AACE/ACE/AME 26% vs. ACR TI-RADS 20.5%). A total of 14 nodules that would not have been aspirated were malignant, 13 of which were microcarcinomas (92.8%).DiscussionThe TNAPP algorithm is a reliable, easy-to-learn tool that can be readily employed to improve the selection of thyroid nodules requiring cytological characterization. The rate of malignant nodules missed because of inaccurate characterization at baseline by TNAPP was lower compared to the other two algorithms and, in almost all the cases, the tumors were microcarcinomas. TNAPP’s use of size >20 mm as an independent determinant for considering or recommending FNA reduced its specificity.ConclusionTNAPP performs well compared to AACE/ACE/AME and ACR-TIRADS algorithms. Additional retrospective and, ultimately, prospective studies are needed to confirm and guide the development of future iterations that incorporate different risk stratification systems and targets for diagnosing malignancy while reducing unnecessary FNA procedures

Parathyroid Retrospective Analysis of Neoplasms Incidence (pTRANI Study): An Italian Multicenter Study on Parathyroid Carcinoma and Atypical Parathyroid Tumour

Background: Parathyroid cancer (PC) is a rare sporadic or hereditary malignancy whose histologic features were redefined with the 2022 WHO classification. A total of 24 Italian institutions designed this multicenter study to specify PC incidence, describe its clinical, functional, and imaging characteristics and improve its differentiation from the atypical parathyroid tumour (APT). Methods: All relevant information was collected about PC and APT patients treated between 2009 and 2021. Results: Among 8361 parathyroidectomies, 351 patients (mean age 59.0 ± 14.5; F = 210, 59.8%) were divided into the APT (n = 226, 2.8%) and PC group (n = 125, 1.5%). PC showed significantly higher rates (p < 0.05) of bone involvement, abdominal, and neurological symptoms than APT (48.8% vs. 35.0%, 17.6% vs. 7.1%, 13.6% vs. 5.3%, respectively). Ultrasound (US) diameter >3 cm (30.9% vs. 19.3%, p = 0.049) was significantly more common in the PC. A significantly higher frequency of local recurrences was observed in the PC (8.0% vs. 2.7%, p = 0.022). Mortality due to consequences of cancer or uncontrolled hyperparathyroidism was 3.3%. Conclusions: Symptomatic hyperparathyroidism, high PTH and albumin-corrected serum calcium values, and a US diameter >3 cm may be considered features differentiating PC from APT. 2022 WHO criteria did not impact the diagnosis

Direct-acting antivirals and hepatocellular carcinoma in chronic hepatitis C: A few lights and many shadows

With the introduction of direct-acting antiviral agents (DAA), the rate of sustained virological response (SVR) in the treatment of hepatitis C virus (HCV) has radically improved to over 95%. Robust scientific evidence supports a beneficial role of SVR after interferon therapy in the progression of cirrhosis, resulting in a decreased incidence of hepatocellular carcinoma (HCC). However, a debate on the impact of DAAs on the development of HCC is ongoing. This review aimed to analyse the scientific literature regarding the risk of HCC in terms of its recurrence and occurrence after the use of DAAs to eradicate HCV infection. Among 11 studies examining HCC occurrence, the de novo incidence rate ranged from 0 to 7.4% (maximum follow-up: 18 mo). Among 18 studies regarding HCC recurrence, the rate ranged from 0 to 54.4% (maximum "not well-defined" followup: 32 mo). This review highlights the major difficulties in interpreting data and reconciling the results of the included studies. These difficulties include heterogeneous cohorts, potential misclassifications of HCC prior to DAA therapy, the absence of an adequate control group, short follow-up times and different kinds of follow-up. Moreover, no clinical feature-based scoring system accounts for the molecular characteristics and pathobiology of the tumours. Nonetheless, this review does not suggest that there is a higher rate of de novo HCC occurrence or recurrence after DAA therapy in patients with previous HCV infection. \ua9 2018 The Author(s). Published by Baishideng Publishing Group Inc. All rights reserved

Mid-term echocardiographic results with different rings following restrictive mitral annuloplasty for ischaemic cardiomiopathy

BACKGROUND: Despite restrictive mitral annuloplasty (RMA) being considered effective for chronic ischaemic mitral regurgitation (CIMR), few data exist on mid-term echocardiographic results with different prosthetic rings. Therefore, comparative echocardiographic analysis has been performed. METHODS: Sixty-four consecutive coronary artery bypass graft surgery (CABG) + RMA (downsizing by two-ring sizes; median size: 26 mm) for CIMR with a follow-up of at least 6 months were prospectively followed-up with serial echocardiograms (preoperative, discharge, 6 months, follow-up ending). Hospital mortality, follow-up clinical and echocardiographic results were analysed and compared between three groups (group A: semi-rigid band, 17 patients; group B: complete symmetric semi-rigid, 22 patients; group C: complete asymmetric semi-rigid, 25 patients). RESULTS: Hospital mortality was 6.3%; 22.8 +/- 14.7 standard deviation (SD) months (range: 6-55) survival was 96.5 +/- 2.5%; freedom from re-intervention was 94.2 +/- 4.2%, from re-revascularisation 87.5 +/- 11.7%, from > or = grade-2 mitral regurgitation 58.2 +/- 9.8% and from heart failure (CHF) 71.6 +/- 10.5%. Recurrent (> or = grade-2) CIMR resulted in lower freedom-from-CHF (p = 0.0001), worsened New York Heart Association (NYHA) classification (p = 0.0001) and absence of reverse remodelling of the left ventricular end-diastolic diameter (LVEDD; p = 0.004), systolic diameter (LVESD; p = 0.014), indexed mass (LVMi; p = 0.005) and coaptation depth (p = 0.0001). Group A showed significant worse freedom from CHF (group A: 42.8 +/- 19.5% vs group B: 88.9 +/- 10.5% vs group C: 92.3 +/- 7.5%; p = 0.049) and from recurrent CIMR (17.4 +/- 13.8% vs 82.1 +/- 11.7% vs 94.1 +/- 5.7%, respectively; p = 0.0001). Complete rings decreased the hazard of recurrent CIMR (Physio = 0.141; Adams = 0.089). Higher NYHA during follow-up was found in group A (p = 0.002 for group B and p = 0.001 for group C) with a progressive reduction of trans-mitral mean gradient (p = 0.001), and a lower degree of reverse remodelling of LVEDD (p = 0.009 and p = 0.010) and coaptation depth (p = 0.040 and p = 0.002). CONCLUSIONS: Recurrent CIMR correlates with absent ventricular reverse remodelling. Despite a higher trans-mitral gradient, complete rings achieve better results in the treatment of CIMR

Midterm clinical and echocardiographic results and predictors of mitral regurgitation recurrence following restrictive annuloplasty for ischemic cardiomyopathy

OBJECTIVE: Although mitral restrictive annuloplasty plus coronary artery bypass grafting are considered the best therapeutic strategies for ischemic cardiomyopathy with chronic mitral regurgitation, some recurrences are still reported. We evaluated predictors for late recurrence of ischemic cardiomyopathy with chronic mitral regurgitation. METHODS: Hospital outcome and serial clinical and echocardiographic (preoperative, discharge, 6 months, end of follow-up) follow-up assessments were recorded for 82 consecutive patients with ischemic cardiomyopathy with chronic mitral regurgitation having coronary artery bypass grafting + mitral restrictive annuloplasty (2 sizes ring downsizing). Recurrent ischemic cardiomyopathy with chronic mitral regurgitation was defined by grade >or= 2 at echocardiography. RESULTS: Hospital mortality was 4.9%; 17.7 +/- 1.7 (standard error) months (range 1-55) survival was 95.5% +/- 2.5%. Two-year Kaplan-Meier freedom from reintervention was 94.2% +/- 4.2%; from rerevascularization, 87.5% +/- 11.7%; from congestive heart failure, 83.8% +/- 5.7%; from ischemic cardiomyopathy with chronic mitral regurgitation grade >or= 2, 46.5% +/- 11.2%. Recurrence of ischemic cardiomyopathy with chronic mitral regurgitation gave lower 2-year Kaplan-Meier freedom from death (P = .03) and lower 2-year freedom from congestive heart failure (P = .0001), reintervention (P = .034), and tricuspid insufficiency (P = .0001). Ischemic cardiomyopathy with chronic mitral regurgitation recurrence correlated with worsened New York Heart Association class (P = .0001), left ventricular ejection fraction (P = .024), pulmonary arterial pressures (P = .0001), left ventricular end-diastolic diameter (P = .004), left ventricular end-systolic diameter (P = .014), indexed left ventricular mass (P = .008), and coaptation depth (P = .0001). Independent predictors for recurrent ischemic cardiomyopathy with chronic mitral regurgitation were previous anterior + posterior myocardial infarction (odds ratio 3.70; confidence interval 2.93-5.41; P = .001), preoperative left ventricular end-diastolic diameter >or= 70 mm (odds ratio 3.91; confidence interval 2.65-5.22; P = .001), and coaptation depth at discharge >or= 0.5 cm (odds ratio 11.9; confidence interval 5.91-21.34; P = .0001). Preoperative left ventricular end-diastolic diameter >or= 70 mm correlated with higher congestive heart failure (P = .002), recurrent ischemic cardiomyopathy with chronic mitral regurgitation (P = .0001), worsened New York Heart Association class (P = .0001), and higher diuretics (P = .0001). Coaptation depth < 0.5 cm at discharge accounted for better survival (P = .010), lower incidence of congestive heart failure (P = .0001), lower need for diuretics (P = .0001), and improved New York Heart Association class (P = .0001). CONCLUSIONS: Failure of mitral restrictive annuloplasty is responsible for follow-up mortality and congestive heart failure and correlates with absence of cardiac reverse remodeling. Prognosis of patients having mitral restrictive annuloplasty for ischemic cardiomyopathy with chronic mitral regurgitation is good, as long as a low postoperative coaptation depth is achieved. Patients with significant left ventricular dilation should be considered for different surgical strategies

Trachy-phonolite lava pebbles used in the ancient settlement of Oplontis (Torre Annunziata, Naples): petrochemical data supporting the origin from an old effusive activity of the Somma-Vesuvius volcano

In the southern and south-eastern sectors of Somma-Vesuvius volcano (Campania region, southern Italy), archaeological sites covered by the deposits of A.D. 79 Vesuvius eruption, and dating back to Protohistoric and Roman periods are characterized by the presence of numerous lava pebbles used in the human settlements. In this work we present the new case study of the lava samples found with other materials used in building foundations of the Roman site of Oplontis (the “Villa of Poppea” or “Villa A” or Oplontis A; and the ancient commercial structure of Oplontis B). This new data set of lava pebbles of different lithologies was also compared with that of the archaeological site of Longola, in order to unravel the source provenance from distinct evolutionary phase of the Somma-Vesuvius volcano. According to major and trace elements composition, lava pebbles are all compatible with the Somma-Vesuvius magmas erupted before 8 ka BP and are represented, according to modal mineralogy and whole-rock geochemistry, by two groups belonging to the slightly silica undersaturated series: several basic-intermediate lithotypes (mainly phonolitic tephrites to basaltic trachyandesites) and trachy-phonolites. Despite the obvious abundance of volcanic rock pebbles, as the settlements were built on the Somma-Vesuvius volcano, the trachyphonolite lava pebbles do not match with any lithostratigraphic units mapped in the up-to-now available literature data. Nevertheless, the trachy-phonolite lava pebbles show (i) a comagmatic relationships with the products erupted by Somma-Vesuvius before 8 ka BP as pyroclastic products (i.e. pumices) and (ii) a good petrological affinity with lava trachyte ejecta included within the Plinian eruptions preceding the A.D. 79 event. The basic-intermediate and the trachy-phonolite lava pebbles from both the sites of Oplontis and Longola, have to be interpreted as an old effusive activity of the Somma-Vesuvius. In order to form lava pebbles, reworking could have taken place both on the original lava flows/autoclastic breccias or the lithic lava fragments of pyroclastic/breccia deposits produced by the explosive events preceding the A.D. 79 eruption

Successful surgical treatment of chronic ischemic mitral regurgitation achieves left ventricular reverse remodeling but does not affect right ventricular function

OBJECTIVE: To evaluate left-sided and right-sided heart echocardiographic results after restrictive mitral annuloplasty in chronic ischemic mitral regurgitation. METHODS: Left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, left ventricular ejection fraction, left ventricular indexed mass, coaptation depth, transmitral mean gradient, systolic pulmonary arterial pressure, tricuspid annular plane systolic excursion, right ventricular ejection fraction, and tricuspid insufficiency grading were evaluated preoperatively, postoperatively, at 6 months, and at the end of the follow-up period in 64 patients undergoing restrictive mitral annuloplasty and coronary artery bypass grafting. Recurrence of chronic ischemic mitral regurgitation was defined as 2+/4+ grade or greater mitral regurgitation at any time postoperatively. RESULTS: Twenty-two months of freedom from recurrent chronic ischemic mitral regurgitation was 58.2% +/- 9.8%. Recurrent chronic ischemic mitral regurgitation did not lead to reverse remodeling of left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and ventricular indexed mass (P = not significant), with increased coaptation depth, parallel to follow-up chronic ischemic mitral regurgitation worsening. Effective restrictive mitral annuloplasty induced reverse remodeling of left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and ventricular indexed mass, improved left ventricular ejection fraction, shortened coaptation depth, and improved mean gradient (P <or= .014). Recurrent chronic ischemic mitral regurgitation in patients without tricuspid surgery prevented improvements of systolic pulmonary arterial pressure, tricuspid annular plane systolic excursion, right ventricular ejection fraction, worsening New York Heart Association (P = .003), and daily diuretic need (P = .008), whereas effective restrictive mitral annuloplasty progressively improved tricuspid insufficiency grading, systolic pulmonary arterial pressure, right ventricular ejection fraction, tricuspid annular plane systolic excursion, New York Heart Association, and diuretic need (P <or= .013). Patients undergoing tricuspid annuloplasty did not show any improvement of systolic pulmonary arterial pressure, right ventricular ejection fraction, and tricuspid annular plane systolic excursion regardless of the recurrence of chronic ischemic mitral regurgitation (P = not significant), although effective restrictive mitral annuloplasty improved tricuspid insufficiency grading, New York Heart Association, and daily diuretic need (P <or= .010). CONCLUSION: Effective restrictive mitral annuloplasty induces reverse left ventricular remodeling. Absence of recurrent chronic ischemic mitral regurgitation improves tricuspid insufficiency grading, systolic pulmonary arterial pressure, right ventricular ejection fraction, tricuspid annular plane systolic excursion, New York Heart Association, and diuretic need in patients who do not undergo tricuspid surgery, but only tricuspid insufficiency grading, New York Heart Association, and daily diuretic need in patients who undergo tricuspid surgery