[Show abstract][Hide abstract] ABSTRACT: The aim of the present prospective study was to evaluate the predictive value of elastography in benign thyroid nodules of patients affected by Hashimoto's thyroiditis (HT). From January 2011 to January 2012, 242 nodules in patients affected by HT were submitted to fine needle aspiration cytology (FNAC). All of the patients underwent sonography and elastography performed before FNAC. 230 (95%) nodules were benign, 8 papillary cancers, and 4 follicular lesions. Score 1 was found in 79.1% of benign lesions (sensitivity 79.1%; specificity 66.7%; PPV 97.8%; NPV 14.3%; accuracy 78.5%; p < 0.05). In order to evaluate the outcome of thyroid ultrasound echogenicity in relation to elastography features of nodule(s), all the patients with benign nodules were stratified according to their hypoechoic pattern of thyroid (mild-moderate and severe). Following stratification score 1 was found in 84.2% of benign nodules (sensitivity 75.0%; specificity 88.9%; PPV 27.3%; NPV 98.4%; accuracy 88.2%; p < 0.0001) of patients with a mild-moderate ultrasound thyroid hypoechogenicity, whereas it was found in 60% of benign nodules (p = 0.715) of patients with a marked thyroid hypoechogenicity. Elastography appears to have limited value in detecting thyroid cancer in patients affected by Hashimoto's thyroiditis with severe hypoechoic thyroid tissue.
International Journal of Endocrinology 08/2015; 2015(11):367054. DOI:10.1155/2015/367054 · 1.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose
Recent evidences suggest that, despite the large use of levothyroxine (L-T4), up to 40% of patients are over-treated developing sub-clinical hyperthyroidism. We compared TSH, fT4 and fT3 serum levels of elderly patients in treatment with liquid and tablet L-T4 formulations over a period of time of five years.
Patients were recruited by searching the database of those treated and followed at the Thyroid Unit of the University of Brescia.
Two hundred and ninety-nine patients (251 females, 48 males) were treated with L-T4 in tablet form (group T) and 118 subjects (107 female, 11 male) with liquid LT4 (group L). The two groups were super-imposable by age, median L-T4 dosage, TSH, fT4 and fT3 values. A slightly but not significantly higher BMI value was observed among patients of group L over those of group T (26.9 ± 2.9 vs. 26.4 ± 2.1 kg/cm2, respectively). During five years of LT-4 treatment, sub-clinical or over-hypothyroidism was found in 13 (4.3%) and 3 (2.5%) patients of group T and group L (P = 0.335), whereas, subclinical or clinical hyperthyroidism was significantly more frequent among patients of group T than those of group L [69 (23%) vs. 5 (4.2%) patients, (P = 0.0001)]. Logistic regression analysis showed that only the Tablets were associated with the risk of developing subclinical or hyperthyroidism [OR 2·354 (1·136–4·827), P = 0.021].
We show a greater stability in the thyroid profile of hypothyroid elderly patients in treatment with liquid thyroxine as opposed to those being treated by tablet formulation over five years of follow-up.
European geriatric medicine 12/2014; 5(6). DOI:10.1016/j.eurger.2014.09.006 · 0.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The majority of clinicians suggest that enteral feedings should be held 1-2 h prior to and after L-T4 administration despite lack of data for continuous enteral nutrition.
The aim of this study was to: (1) compare the thyroid hormonal profile in patients submitted to L-T4 treatment in tablets or liquid formulation with an enteral feeding tube; (2) evaluate the nursing compliance with the two different formulations.
20 euthyroid patients submitted to total laryngectomy and thyroidectomy consecutively started L-T4 treatment in tablets (Group T) or in liquid formulation (Group L) with enteral feeding tube the day after surgery. Tablets were crushed before administration and enteral feeding was stopped for 30 min before and after L-T4 treatment, whereas liquid formulation was placed into the nasoenteric tube immediately. A questionnaire about the preparation and administration of thyroxine replacement therapy was given to the nurses.
No difference of TSH, fT4 and fT3 before and after L-T4 treatment was observed among patients of Group L. A slightly serum TSH increase was observed in Group T, but not reaching statistical significance (2.50 ± 1.18 vs 2.94 ± 1.22 mUI/L), whereas no difference in fT4 and fT3 levels was found. Preparation and administration of liquid L-T4 was considered excellent by 12/13 nurses, whereas tablet formulation was considered poor by 10/13.
Our data showed that liquid L-T4 formulation can be administered directly through feeding tube with no need for an empty stomach, with a significant improvement in therapy preparation and administration by nurses.
[Show abstract][Hide abstract] ABSTRACT: Levothyroxine (L-T4) treatment with coffee, or with water followed by coffee within a few minutes, results in poor TSH response in many patients. Thyroxine is worldwide suitable in tablets form but novel formulations in soft gel capsule or liquid formulation are now available.
We fortuitously observed an euthyroid patient who wrongly assumed liquid L-T4 with coffee at breakfast: after changing the assumption thirty minutes before breakfast, no change of TSH, fT4 and fT3 was observed. Once the first patient was identified, we identified additional stable euthyroid patients who assumed liquid L-T4 with coffee.
Patients were recruited by searching our "thyroid patients" database. All patients on liquid L-T4 treatment were contacted by phone to find out if L-T4 was taken at breakfast. We identified fifty-four patients that were submitted to TSH, fT4 and fT3 evaluation, with the following indication to assume the same dosage of L-T4 half hour before breakfast. We checked again their TSH, fT4 and fT3 values, 3 and 6 months later.
No significative difference of thyroid hormonal values was observed between patients who assumed L-T4 at breakfast and after 3 and 6 months of its assumption half hour before breakfast [TSH : 2.5±1.1 vs 2.5±1.1 and 2.4±1.1 (mIU/L), respectively], [fT4: 12.4±2.4 vs 12.5±2.4 and 12.3±2.1 (pg/mL), respectively] and [fT3: 3.4±0.6 vs 3.4±0.6 and 3.3±0.5 (pg/mL), respectively].
Oral liquid L-T4 could remove the problem of L-T4 malabsorption by coffee observed with traditional tablets formulations.
European Journal of Endocrinology 10/2013; 170(1). DOI:10.1530/EJE-13-0693 · 4.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: High resolution ultrasonography features have also been described as having a useful supporting role in the diagnosis of subacute granulomatous thyroiditis (ST), and images are generally characterized by heterogeneous hypoechoic areas of the affected tissue with lack of flow on color Doppler US.
To determine the sonographic features of subacute granulomatous thyroiditis.
We reviewed the medical records of patients referred at the Endocrine and Metabolic Unit of our Institution between January 2010 and December 2011.
A total of 7520 patients were evaluated in our department between January 2010 and December 2011. Among them, 22 (0.3%) patients had a diagnosis of ST (19 women and 3 men, 45.4 ± 9.7 year; range, 33-62 years). Ultrasound examination showed bilateral ST in 64% of patients. Thyroid volume was 13.2 ± 7.7 mL, without difference if ST was unilateral (13.2 ± 7.1 mL) or bilateral (13.9 ± 8.3 mL). On grayscale US, heterogeneous diffusely or focally marked hypoechoic areas, like "lava flow", were found in all the lesions.
Our data confirm the high sensitivity of US in the diagnosis of ST: diffuse hypoechoic and confluent areas with the characteristic features like "lava flow".
[Show abstract][Hide abstract] ABSTRACT: 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.
Obesity Surgery 07/2013; 23(9). DOI:10.1007/s11695-013-1015-y · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Metformin may lower or even suppress serum levels of thyroidstimulating hormone (TSH), mimicking sub-clinical hyperthyroidism (SHT), but the clinical significance of this effect remains controversial. Although commonly asymptomatic, SHT involves an increased risk of cardiac arrhythmias, mostly atrial fibrillation, morphological and functional cardiac alterations, resulting in increased cardiovascular morbidity and mortality. The present study retrospectively evaluated changes in several electrocardiographic indices in euthyroid diabetic patients who, after starting metformin treatment, had lower serum TSH than patients with SHT resulting from an underlying thyroid disease or TSH suppressive treatment with L-thyroxine. Electrocardiographic parameters (heart rate, P-wave duration, P-wave dispersion, QTmax, QTmin and QT-dispersion) were assessed in 23 patients with diabetes treated with metformin before and after six months of TSH-suppression and in 31 control patients with SHT. There were no significant changes in electrocardiographic parameters from baseline to the TSHsuppression measurements. By contrast, there were significant differences in P wave duration (102.9 ± 7.4 vs 92.1 ± 5.8 ms, p < 0.001), P wave dispersion (13.1 ± 3.4 vs 7.1 ± 3.5 ms, p < 0.001), QTmax (399 ± 18 vs 388 ± 16 ms, p = 0.024), QTmin (341 ± 14 vs 350 ± 17 ms, p = 0.038), and QT dispersion (49.9 ± 9.6 vs 30.9 ± 9.2 ms, p < 0.001) between the control patients with SHT and the diabetic patients with similarly low serum TSH. These findings indicate that the TSH-suppressive effect observed in some patients with diabetes taking metformin is not associated with peripheral markers of thyroid hormone excess, at least at the cardiac level. The metformin-induced biochemical condition does not appear to be indicative of SHT, suggesting there is no need for close thyroid function surveillance in diabetic patients starting metformin.
Giornale Italiano di Diabetologia e Metabolismo 12/2012; 32(4):176-181.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
The aim of this study was to evaluate the predictive value of sonography and sonographic elastography in thyroid nodules with nondiagnostic cytologic findings.
The study included 101 patients (74 female, mean age ± SD, 55 ± 11 years [range, 27-70 years]; and 27 male, mean age, 62 ± 9 years [range, 42-72 years]) who had at least 1 nodule with nondiagnostic cytologic findings at two different fine-needle aspiration cytologic evaluations and with an indication for hemi or total thyroidectomy for clinical suspicion of malignancy, nodule size, or the occurrence of a coexisting nodule with cytologic findings suspicious for malignancy. All of the patients underwent sonography and elastography 2 months after the second fine-needle aspiration and before surgery. The elastogram was matched with an elasticity color scale and classified as follows: score 1, nodules with high elasticity (soft); score 2, nodules with indeterminate elasticity; and score 3, nodules with low elasticity (hard).
A total of 135 nodules (93.7%) were hyperplastic; 15 (9.4%) were papillary carcinomas; and 9 (6.3%) were follicular adenomas. The association of scores 2 and 3 identified 12 of 15 thyroid cancers (sensitivity, 80.0%; specificity, 93.7%; positive predictive value, 57.1%; negative predictive value, 97.8%; and accuracy, 92.4%), whereas the association of conventional sonographic features plus scores 2 and 3 identified all of the cancers (specificity, 70.8%; positive predictive value, 26.3%; negative predictive value, 100%; and accuracy, 73.6%).
Our data suggest that elastography could be a promising tool in the management of nodules that are nondiagnostic at cytologic evaluation, reducing unnecessary surgery.
Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 11/2012; 31(11):1777-82. · 1.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The European Thyroid Association (ETA) and the American Thyroid Association (ATA) guidelines identify subgroups of patients affected by thyroid carcinoma in whom, due to a low risk of recurrence, radioiodine ablation is not indicated. These patients are referred to as "very low-risk" according to the ETA consensus and "low-risk" patients according to the ATA guidelines. The recommended post-surgical follow-up of these patients is based upon periodical measurements of serum thyroglobulin (Tg) on levothyroxine therapy and neck ultrasound (US).
To evaluate the usefulness of recombinant human (rh)-TSH Tg test and its repetition 2-3 yr afterwards in very low-risk patients.
We consecutively enrolled 32 patients with undetectable anti-Tg antibodies. Basal serum Tg levels was undetectable in all patients.
Following rhTSH serum Tg remained undetectable in 23 (71.9%) patients (UP) and was >1.0 ng/ml in 9 (DP). US and whole body scan, revealed lymph node metastasis in 4/9 DP patients. A second rhTSH stimulation test (36.9±3.5 months later) was performed in all UP and in 5 DP patients without proven recurrences. All the UP and 4/5 formerly DP patients showed undetectable Tg stimulation.
Our results suggest that rhTSH Tg test may be helpful in very low-risk patients, given its ability to differentiate those who may be considered "free of disease" from those who require further investigation and treatment. Repeated rhTSH Tg tests may be indicated only in patients with detectable serum Tg at prior stimulation testing.
[Show abstract][Hide abstract] ABSTRACT: A relevant biological role of circulating endothelial progenitor cells (EPC) was recently demonstrated. EPC are generated in the bone marrow, and interact with damaged endothelium, restoring the integrity of the monolayer. Therefore, aim of the present study was to evaluate EPC in the blood of patients with untreated Graves' hyperthyroidism (GD), in whom an increased oxidative stress was observed.
Twenty-three patients with untreated active GD and 18 matched normal controls (NC) were included in the study. Circulating EPC were isolated from peripheral blood. Mononuclear cells were cultured with endothelial basal medium supplemented with EGM SingleQuots, and were identified by positive double staining after 7 days in culture. Circulating levels of C reactive protein, total antioxidant power, interleukin (IL)-6, IL- 18, monocyte chemoattractant protein-1, tumor necrosis facotr- α, soluble vascular cell adhesion molecule (VCAM) and intracellular adhesion molecule were evaluated by enzymelinked immunosorbent assay kit. EPC number was also evaluated in a subgroup of GD patients after restoration of euthyroidism.
Systolic blood pressure resulted increased in GD patients compared with control subjects whereas diastolic blood pressure was not significantly different. Patients with GD showed an increase in circulating levels of IL-18 and VCAM-1 and a reduction of total antioxidant power (p<0.05) compared to NC. Moreover, a reduced number of EPC was observed in patients with GD compared to NC (p<0.05) which turned to NC values after restoring euthyroidism.
Patients with GD showed a reduction in the physiological protective mechanisms against endothelial damage, probably induced by increased inflammation and oxidative stress.
[Show abstract][Hide abstract] ABSTRACT: To assess the interplay between metformin treatment and thyroid function in type 2 diabetic patients.
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.
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.
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.
Diabetes care 06/2009; 32(9):1589-90. DOI:10.2337/dc09-0273 · 8.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Ultrasound-guided fine needle aspiration cytology (US-FNAC) represents the most effective test available to distinguish between benign and malignant thyroid nodules. The major limit is the rate of inadequate specimens which generates a much higher cost. The aim of the present study was to evaluate whether the adoption of stylet needles may result in a significant improvement of diagnostic performance in a large, unselected series of nodules.
1468 nodules were submitted to US-FNAC by two different 25-gauge needles: a traditional hollow needle (Ns) or a stylet needle (Ys). Cytological specimens were evaluated in blind conditions by the same cytopathologist.
Ys was associated to a significant reduction of non-diagnostic specimens (2.8% vs 9.1% by Ns, respectively, P < 0.001). Logistic regression analysis taking into account sex, age, needle type, nodule size, multiplicity and structure predictor of successful sampling [odds ratio 3.6 (95.0% CN 2.0-6.4), P < 0.001]. The cost analysis comparing the adoption of the two types of needle evidenced that the cost per adequate specimen was consistently less for Ys than for Ns (euro 78.87 vs euro 90.76).
Our data showed that the adoption of a stylet needle significantly improves diagnostic performance, reducing by about 14% the expenditure per diagnostic procedure. Therefore, we suggest that stylet needles should be widely adopted to perform US-FNAC of thyroid procedures.
Southern medical journal 04/2009; 102(5):498-501. DOI:10.1097/SMJ.0b013e31819c7343 · 0.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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
Case Reports in Medicine 02/2009; 2009:535974. DOI:10.1155/2009/535974
[Show abstract][Hide abstract] ABSTRACT: 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.
QJM: monthly journal of the Association of Physicians 06/2008; 101(8):657-62. DOI:10.1093/qjmed/hcn062 · 2.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: As a consequence of increasing application of ultrasound technology, the detection of asymptomatic thyroid nodules has generally increased. In fact, ultrasound epidemiological studies report that two third of subjects have at least a thyroid nodule, instead of 4-7% detected by clinicians. These evidences suggest the need of a rational approach to the thyroid nodule ''epidemia''. The question of whether clinically unapparent thyroid lesions should be assessed by cytology is still unresolved and, moreover, the clinical significance of nonpalpable (diameter <10 mm) thyroid carcinoma is still a matter of discussion. Aim of this work is to delineate a rational approach to thyroid nodules, taking in account literature data, the most recent guidelines and our clinical experience.