Suboptimal accuracy of ultrasound and ultrasound-based risk stratification systems in detecting medullary thyroid carcinoma should not be overlooked. Findings from a systematic review with meta-analysis.

OBJECTIVE: Ultrasound (US) is the pivotal procedure during the diagnostic work-up of thyroid nodule and several US-based risk stratification systems (RSSs) have been recently developed. Since the performance of RSSs in detecting medullary thyroid carcinoma (MTC) has been rarely investigated, the present systematic review aimed to achieve high evidence about (1) how MTC is classified according to RSSs; (2) if RSSs correctly classify MTC at high risk/suspicion, and (3) if MTC is classified as suspicious at US when RSSs are not used. DESIGN: The review was performed according to MOOSE. The online search was performed by specific algorithm on January 2022. A random-effects model was used for statistical analysis. RESULTS: Twenty-five papers were initially included and their risk of bias was generally low. According to ATA system, 65% of MTCs was assessed at high suspicion and 25% at intermediate suspicion. Considering all RSSs, a 54.8% of MTCs was put in a high-risk/suspicion category. Pooling data from studies without data of RSS the prevalence of ultrasonographically suspicious MTCs was 60%. CONCLUSIONS: As conclusion, MTC presentation according to RSSs is partially known and it is classified in a high-risk/suspicion category of RSSs in just over a half of cases. This advises for further studies, ideally supported by international societies, to better define the US presentation of MTC.

Reactive hypoglycaemia during the OGTT after gestational diabetes mellitus: Metabolic implications and evolution.

AIMS: Gestational diabetes (GDM) presents an increased cardio-metabolic risk and is diagnosed with an oral glucose tolerance test (OGTT). Reactive hypoglycaemia (RH) during the OGTT in pregnancy is associated with adverse outcomes. Although postpartum OGTT after GDM is recommended, the occurrence and implications of RH are unknown. We investigated the prevalence, metabolic implications and longitudinal evolution of RH at 6-8 weeks postpartum in women with a history of GDM. METHODS: Between 2011 and 2021, we consecutively followed 1237 women with previous GDM undergoing an OGTT at 6-8 weeks postpartum. RH was defined as 2-h glucose <3.9 mmoL/L after the OGTT. Metabolic outcomes were compared in women with and without RH (RH+/RH-). We also included a subcohort of 191 women with data on insulin sensitivity/secretion indices (MATSUDA, HOMA-IR, insulin-adjusted-secretion ISSI-2). RESULTS: The postpartum prevalence of RH was 12%. RH+ women had a more favourable metabolic profile including a 2-5-times lower prevalence of glucose intolerance and metabolic syndrome at 6-8 weeks postpartum compared to RH- (all p ≤ 0.034). In the subcohort, women with RH+ had higher insulin sensitivity, higher ISSI-2 and an earlier glucose peak after OGTT (p ≤ 0.049) compared to RH- women at the same time point. Insulin resistance increased and ISSI-2 decreased over the first year postpartum in both groups. These changes were associated with a 50% reduction in overall RH prevalence at 1-year postpartum. Some of the favourable profiles of RH+ persisted at 1-year postpartum, without group differences in the longitudinal metabolic changes. CONCLUSIONS: At 6-8 weeks postpartum, RH was frequent in women after GDM and associated with a better metabolic profile including increased insulin sensitivity and higher insulin-adjusted-secretory capacity. RH might be a marker of favourable metabolic prognosis in women with a history of GDM.

Thyroid sequelae of COVID-19: a systematic review of reviews.

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has the potential to cause multi-organ effects including endocrine disorders. The impact of COVID-19 on the thyroid gland has been described but several aspects have to be clarified. The systematic review was conceived to achieve more solid information about: 1) which thyroid disease or dysfunction should be expected in COVID-19 patients; 2) whether thyroid patients have a higher risk of SARS-CoV-2 infection; 3) whether the management has to be adapted in thyroid patient when infected. The literature was searched by two authors independently. A 5-step search strategy was a priori adopted. Only reviews focused on the relationship between thyroid and COVID-19 were included. The last search was performed on February 21st 2021. Two-hundred-forty-seven records was initially found and nine reviews were finally included. The reviews identified several potential thyroid consequences in COVID-19 patients, such as thyrotoxicosis, low-T3 syndrome and subacute thyroiditis, while no relevant data were found regarding the potential impact of COVID-19 on the management of patients on thyroid treatment. The present systematic review of reviews found that: 1) patients diagnosed with COVID-19 can develop thyroid dysfunction, frequently non-thyroidal illness syndrome when hospitalized in intensive care unit, 2) having a thyroid disease does not increase the risk for SARS-CoV-2 infection, 3) thyroid patients do not need a COVID-19-adapted follow-up. Anyway, several factors, such as critical illness and medications, could affect thyroid laboratory tests.

[Treatment of type 2 diabetes before, during and after metabolic surgery]. / Traitement du diabète de type 2 avant, pendant et après la chirurgie métabolique.

Metabolic surgery is becoming increasingly important in the treatment of obese and diabetic patients. Its impact is major on immediate post-operative glycemic control and adaptation of anti-diabetic treatments is necessary. Over time, a recurrence of diabetes may be observed and the choice of treatments to be reintroduced must take into account the surgery performed. By discussing pharmacological options during the preoperative, peri-operative and post-operative periods, this article provides a review of the literature on a subject for which few guidelines are currently proposed.

La chirurgie métabolique prend une place toujours plus importante dans l'offre de traitement des patients obèses et diabétiques. Son impact est radical sur l'équilibre glycémique postopératoire immédiat et une adaptation rapide des traitements antidiabétiques est nécessaire. Au fil du temps, une récidive du diabète peut être observée et le choix des traitements à réintroduire doit tenir compte de l'intervention chirurgicale effectuée. En discutant les options pharmacologiques durant les périodes préopératoire, périopératoire et postopératoire, cet article propose une revue de la littérature sur un sujet pour lequel peu de directives sont actuellement proposées.

[Insulin pump treatment: For whom and how to set it up on an outpatient?] / Traitement par pompe à insuline : pour qui et comment le mettre en place en ambulatoire ?

Pump therapy has existed for over 40 years and provides a more flexible delivery of insulin. To date, almost 25% of type 1 diabetic patients have chosen this therapeutic option. In recent years, it has also been offered to patients with type 2 insulin-requiring diabetes. The choice of insulin pump is based on its indication, the patient's preference, lifestyle and knowledge of the disease. A risk of developing ketoacidosis in case of interruption of insulin delivery exists. Its implementation therefore requires a specialized interdisciplinary care team available in case of emergency.

L'insulinothérapie par pompe existe depuis plus de 40 ans et permet une délivrance plus flexible de l'insuline. À ce jour, près de 25% des patients diabétiques de type 1 ont choisi cette option thérapeutique. Depuis quelques années, elle est aussi proposée aux patients diabétiques de type 2 insulino-requérants. Le choix de la pompe à insuline repose sur son indication, la préférence du patient, son style de vie et ses connaissances de la maladie. Un risque de survenue d'acidocétose en cas d'interruption de la délivrance d'insuline existe. Sa mise en place nécessite donc une équipe de soins interdisciplinaire spécialisée et disponible en cas d'urgence.

Risk of TIRADS-based inappropriate FNAC in autonomous thyroid nodules is clinically negligible.

OBJECTIVE: Thyroid nodule (TN) is usually managed according to Thyroid Imaging And Reporting Data Systems (TIRADS) with the major aim to reduce as much as possible unnecessary fine-needle aspiration cytologies (UN-FNACs). Since the assessment of autonomously functioning thyroid nodule (AFTN) according to TIRADS is heterogeneous, that virtually benign entity may increase the rate of UN-FNAC. This study retrospectively analyzed the appropriateness of TIRADS-based FNAC indication in AFTNs, also looking at the impact of TSH and nodule size. METHODS: Cases diagnosed with AFTN on scintigraphy were searched. Patients who had undergone AFTN treatment, were on medications or supplementation that could affect thyroid function, or had multiple AFTNs were excluded. The AFTNs were assessed according to ACR-TIRADS. RESULTS: Forty-eight AFTNs were included and a 37.5% of cases had FNAC indication according to TIRADS. The FNAC indication rate of patients with TSH lower than 0.4 mIU/L was significantly higher than the remaining ones (p = 0.0078). The most accurate cut-off of TSH and AFTN size associated with UN-FNAC was ≤0.41 mIU/L and >22 mm, respectively. The multivariate analysis showed that both TSH and nodule size were independent predictors of UN-FNAC with OR 6.65 and 6.46, respectively. According to these data, the rate of FNAC indication dropped up to 4.16%. CONCLUSION: Inappropriate FNACs in AFTNs are primarily observed in patients with low TSH and large AFTN. Since these cases typically undergo scintigraphy, the risk of TIRADS-based UN-FNAC is clinically negligible. There is no need for integrating other imaging procedures into the TIRADS model.

Continuous Glucose Monitoring and Recreational Scuba Diving in Type 1 Diabetes: Head-to-Head Comparison Between Free Style Libre 3 and Dexcom G7 Performance.

Background: Scuba diving was previously excluded because of hypoglycemic risks for patients with type 1 diabetes mellitus(T1DM). Specific eligibility criteria and a safety protocol have been defined, whereas continuous glucose monitoring (CGM) systems have enhanced diabetes management. This study aims to assess the feasibility and accuracy of CGM Dexcom G7 and Free Style Libre 3 in a setting of repetitive scuba diving in T1DM, exploring the possibility of nonadjunctive use. Material and Methods: The study was conducted during an event of Diabete Sommerso® association in 2023. Participants followed a safety protocol, with capillary glucose as reference standard (Beurer GL50Evo). Sensors' accuracy was evaluated through median and mean absolute relative difference (MeARD, MARD) and surveillance error grid (SEG). Data distribution and correlation were estimated by Spearman test and Bland-Altman plots. The ability of sensors to identify hypoglycemia was assessed by contingency tables. Results: Data from 202 dives of 13 patients were collected. The overall MARD was 31% (Dexcom G7) and 14.2% (Free Style Libre 3) and MeARD was 19.7% and 11.6%, respectively. Free Style Libre 3 exhibited better accuracy in normoglycemic and hyperglycemic ranges. SEG analysis showed 82.1% (Dexcom G7) and 97.4% (Free Style Libre 3) data on no-risk zone. Free Style Libre 3 better performed on hypoglycemia identification (diagnostic odds ratio of 254.10 vs. 58.95). Neither of the sensors reached the MARD for nonadjunctive use. Conclusions: The study reveals Free Style Libre 3 superior accuracy compared with Dexcom G7 in a setting of repetitive scuba diving in T1DM, except for hypoglycemic range. Both sensors fail to achieve accuracy for nonadjunctive use. Capillary tests remain crucial for safe dive planning, and sensor data should be interpreted cautiously. We suggest exploring additional factors potentially influencing sensor performance.

NIFTP-adjusted risk estimation of Bethesda thyroid cytology categories should consider the indication for FNA according to TIRADS.

BACKGROUND: Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was firstly described in 2016. Since NIFTP is thought a non-malignant tumor, the Bethesda system for thyroid cytology proposes two estimations of risk of malignancy of the diagnostic categories, one considering NIFTP as cancer and another one considering it as a benign neoplasm. The present study aimed to review NIFTPs in a single center, re-assess them across categories of three Thyroid Imaging Reporting and Data Systems (TIRADSs), and define the indication for biopsy according to the category-specific size cut-offs. METHODS: The study period was from 2017 to 2023. The institutional database was searched for histologically proven NIFTPs with preoperative ultrasound images. NIFTPs were re-assessed according to the American College of Radiology (ACR), European (EU), and Korean (K) TIRADSs. The indication for biopsy was defined according to TIRADS category-specific size threshold. RESULTS: Twenty NIFTPs from 19 patients were included. The median size of the NIFTPs was 23 mm. According to ultrasound, 80-85% of NIFTPs were at low-intermediate risk and 5-15% at high risk without significant difference among the tree TIRADSs (p = 0.91). The indication for FNA, according to three TIRADSs, was found in 52-58% of cases with no significant difference among systems (p = 0.96). CONCLUSION: NIFTPs have heterogeneous presentation according to TIRADSs with very low indication rate for FNA.

Continuous subcutaneous rhPTH infusion for managing difficult chronic hypoparathyroidism. A systematic review.

PURPOSE: Standard treatment for chronic hypoparathyroidism is represented by long-life per os supplementation of calcium and vitamin D. Since 90s, exogenous PTH is also available, but a not negligible number of patients experience a poor control. Starting from the experience with pumps in diabetes, it has been hypothesized that the infusion of PTH through pump might result in a better disease control. The aim of this systematic review is to summarize the published data about continuous subcutaneous PTH infusion in chronic hypoPTH patients and achieve conclusions for clinical practice. METHODS: A comprehensive computer literature search of the PubMed/MEDLINE, Embase, and Scopus databases was conducted by two authors independently (last search on November 30, 2022). All findings were summarized and critically discussed. RESULTS: We included 14 of the 103 retrieved articles, 2 RCTs, 8 case reports, and 4 case series, published between 2008 and 2022. Of the total 40 patients, 17 were adults, and 23 pediatric. The etiology was postsurgical in 50% of cases and genetic in the other 50%. All had a failure of standard care and a rapid improvement of clinical and biochemical parameters on PTH pump therapy, without severe adverse events. CONCLUSIONS: Based on literature, pump PTH infusion may represent an effective, safe, and feasible option for patients with chronic hypoparathyroidism refractory to standard therapy. From a clinical perspective, careful patient selection, a skilled healthcare team, the assessment of the local setting and the collaboration with pump suppliers are essential.

The performance of levothyroxine tablet is impaired by bariatric surgery.

OBJECTIVE: The aim was to evaluate if bariatric surgery can affect the LT4 performance. The endpoints were the following: 1) difference between LT4 daily dose before and 1 year after surgery, 2) difference between LT4 dose per weight before and 1 year after surgery, 3) difference among LT4 preparations. METHODS: The study period was between January 2018 and May 2022. Inclusion criteria were a) adults undergone bariatric surgery, b) with proven autoimmune hypothyroidism, c) on LT4 therapy before bariatric surgery, d) using any commercialized LT4 preparation. Excluded were patients a) proven to have or suspected for pre-surgical intestinal malabsorption, b) with other potential interfering factors on LT4 absorption; c) with heart, renal, and/or hepatic failure, d) with recent/current infection/inflammation, e) in pregnancy, f) with incomplete data about LT4 therapy. RESULTS: According to the selection criteria, 40 patients were included. Both TSH and LT4 daily doses were not significantly different with respect to baseline values. On the contrary, the LT4 dose per weight was significantly increased, especially in RYGB patients. An increased LT4 dose per weight was observed with the reduction of weight. CONCLUSION: One year after bariatric surgery 1) the daily dose of LT4 remains unchanged, and 2) despite the significant weight reduction, LT4 dose per weight increases. Most data are referred to LT4 tablet and the performance of LT4 caps should be further investigated.

The dilemma of routine testing for calcitonin thyroid nodule's patients to detect or exclude medullary carcinoma: one single negative test should be valuable as rule-out strategy to avoid further calcitonin measurements over time.

PURPOSE: While calcitonin (CT) measurement is recognized as the most accurate tool to diagnose medullary thyroid carcinoma (MTC), its routine use in patients with thyroid nodule (TN) is not universally accepted. The present study raised the question whether a TN patient with an initial normal CT can have suspicious CT levels (i.e., at least >20 pg/ml) later during his follow-up. METHODS: The historical database of our institution was searched to select TN patients undergone multiple CT tests, having an initial normal CT, and clinically followed up for years. The event of a CT above 20 pg/ml (mild-to-moderate suspicion) and 100 pg/ml (high suspicion) was searched in the follow-up of the included patients. RESULTS: According to the study design, the study sample encompassed 170 patients (131 female, 39 male) with initial CT value ≤10 pg/ml. On the first CT test, patients were 54.8 years and median CT was 2.1 pg/ml in both females and males. Over a period of 14.5 years and a median clinical follow-up of patients of 53.0 (23.9-102.5) months, MTC could be excluded by histology or cytology in 109 (64%) and clinically in the remaining ones. On the follow-up over time, no patients had CT >20 pg/ml and only two cases had CT just above 10 pg/ml. CONCLUSION: According to the present results, one single CT testing with normal value could be reasonably used as a rule-out strategy in patients with TN to avoid further CT measurements.

Subacute Thyroiditis during the COVID-19 Pandemic: Searching for a Clinical Association with SARS-CoV-2.

PURPOSE: To search for a clinical potential link between subacute thyroiditis (SAT) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a series of patients diagnosed with SAT during the COVID-19 pandemic, by retrospective evaluation of (1) clinical symptoms and (2) contact tracing. METHODS: SAT patients diagnosed from March to December 2020 were enrolled. The presence of typical clinical presentation of SARS-CoV-2, diagnostic tests for SARS-CoV-2, and contact with other individuals proven to be positive for SARS-CoV-2 were searched. RESULTS: Ten SAT cases were included. Fever was recorded in four patients. Cough, dyspnea, and headache were rarely reported. No patient had diagnosis of pneumonia. Two patients had moderate to severe fatigue after SAT. One patient experienced loss of smell and taste and had persistent fatigue over the following five months. No patient had positive SARS-CoV-2 diagnostic tests. At contact-tracing evaluation, only one patient had a contact with people who were diagnosed with SARS-CoV-2. CONCLUSIONS: Patients diagnosed with SAT during COVID-19 pandemic rarely experienced SARS-CoV-2-related symptomatology. The contact tracing did not show close contact with SARS-CoV-2 individuals in 9/10 cases.

Relapse of Human Chorionic Gonadotropin-Induced Hyperthyroidism and Severe Hyperemesis Gravidarum Secondary to Twin-Twin Transfusion Syndrome, With Rapid Recovery Following Fetoscopic Laser Coagulation: Case Report.

Background: Limited data have shown that, compared to uncomplicated twin pregnancies, pregnancies complicated by twin-twin transfusion syndrome (TTTS), a life-threatening condition, are associated with higher maternal serum levels of both human chorionic gonadotropin (hCG) and thyroid hormones. With the continuing expansion of assisted reproductive technologies, the rate of twin pregnancies, including those complicated by TTTS and associated hyperemesis gravidarum, is expected to increase further. Therefore, detailed descriptions of the maternal and fetal clinical outcomes of maternal thyrotoxicosis linked to TTTS can be useful for timely diagnosis and management. However, such descriptions are currently lacking in the literature. Case Presentation: We report the case of a 30-year-old woman carrying a monochorionic twin pregnancy complicated by TTTS that induced a relapse of severe hyperemesis gravidarum with overt non-autoimmune hyperthyroidism at 17 weeks of gestation. Following fetoscopic laser coagulation (FLC), both hyperemesis and hyperthyroidism improved within 1 week. Conclusions: The present experience contributes to the knowledge base on maternal thyrotoxicosis linked to TTTS and can be useful in the diagnosis and treatment of future cases; it also emphasizes the need for a high degree of clinical suspicion and for close collaboration between endocrinologists and obstetricians. Another key point is that TTTS-associated hyperemesis gravidarum and maternal hyperthyroidism should be considered in the differential diagnosis of refractory or relapsing hyperemesis gravidarum in women with monochorionic twin pregnancy, because this condition may require more stringent supportive treatment before and during the FLC procedure when the mother is overtly hyperthyroid.

Head-to-head comparison among 18F-choline PET/CT, 4D contrast-enhanced CT, and 18F-choline PET/4D contrast-enhanced CT in the detection of hyperfunctioning parathyroid glands: a systematic review and meta-analysis.

INTRODUCTION: In primary hyperparathyroidism (PHPT), the localization of hyperfunctioning parathyroid gland (HPTG) allows tailored surgery. Although Four-Dimensional Contrast-enhanced Computed Tomography (4DCeCT) and 18F-choline Positron Emission Tomography/Computed Tomography (PET/CT) are reported to be promising second-line imaging procedures, no meta-analysis of their comparison exists. DESIGN: we conducted a systematic review and meta-analysis to find original papers reporting the head-to-head comparison of 4DCeCT, 18F-choline PET/CT and integrated 18F-choline-PET/4DCeCT. METHODS: this systematic review was conducted according to PRISMA. PubMed, CENTRAL, Scopus, and Web of Science were searched until January 2021. Studies comparing the ability of 4DCeCT, 18F-choline PET/CT and 18F-choline PET/4DCeCT to identify HPTG in patients with PHPT were selected. A per patient-based analysis of the three procedures was conducted in all patients (detection rate, DR) and in those with histologically confirmed HPTG (sensitivity). RESULTS: Of the 78 records identified, five articles (153 PHPT patients) published between January the 1st, 2018 and January the 31st, 2021 were included. The pooled DR of 18F-choline PET/CT, 4DCeCT and 18F-choline PET/4DCeCT was 0.86, 0.69, and 0.86, respectively, while their pooled sensitivity was 0.89, 0.77 and 0.93, respectively. The analysis of pooled discrepancy showed that the sensitivity of 18F-choline PET/CT and 18F-choline PET/4DCeCT was higher than that of 4DCeCT by 0.11 and 0.13, respectively, the sensitivity of 18F-choline PET/4DCeCT being 0.06 higher than that of 18F-Choline PET/CT. CONCLUSIONS: This meta-analysis suggests that the sensitivity of 18F-choline PET/CT and 18F-choline PET/4DCeCT is higher than that of 4DCeCT, while only a slight difference was observed between 18F-choline PET/CT and 18F-choline PET/4DCeCT.

The Role of CEUS in the Evaluation of Thyroid Cancer: From Diagnosis to Local Staging.

Ultrasound often represents the first diagnostic step for thyroid nodule evaluation in clinical practice, but baseline US alone is not always effective enough to achieve thyroid nodule characterization. In the last decades new ultrasound techniques, such as CEUS, have been introduced to evaluate thyroid parenchyma as recommended by EFSUMB guidelines, for use in clinical research field, although its role is not yet clear. Several papers show the potential utility of CEUS in the differential diagnosis of benign and malignant thyroid nodules and in the analysis of lymph node involvement in neoplastic pathology. Therefore, we carried out an evaluation of the literature concerning the role of CEUS in three specific areas: the characterization of the thyroid nodule, the evaluation of minimally invasive treatment and loco-regional staging of the lymph node in proven thyroid cancer. According to evidence reported, CEUS can also play an operative role in nodular thyroid pathology as it is able to guide ablation procedures on thyroid nodule and metastatic lymph nodes, to assess the radicality of surgery, to evaluate disease relapse at the level of the margins of ablated regions and to monitor the clinical evolution of necrotic areas in immediate post-treatment setting.

Comprehensive Evaluation of Rare Pituitary Lesions: A Single Tertiary Care Pituitary Center Experience and Review of the Literature.

The 2017 World Health Organization classification of central nervous system and endocrine tumors have introduced significant changes in the diagnostic criteria for pituitary lesions. The aim of our paper is to describe the epidemiological, clinico-pathological, and radiological features of a single consecutive institutional surgical series of rare pituitary lesions, using these new criteria. Of the 316 endoscopic endonasal trans-sphenoidal approaches performed for pituitary lesions between 2010 and 2018, 15 rare lesions were encountered. These included metastases, pituitary carcinomas, pituicytomas, granular cell tumor, primary pituitary lymphomas, germinoma, mixed gangliocytoma-adenoma, hypophysitis, and pituitary hyperplasia. Their clinical, radiological, and pathological features are herewith presented along with a literature review that enabled us to propose an algorithm to facilitate a diagnosis for rare pituitary lesions.