Search

Background. Drug-induced hyperthyroidism is a rare condition linked to dietary supplements, iodine-con-taining medications and intentional or unintentional over ingestion of levothyroxine; its detection is important since, if left untreated, thyroid storm can develop, carrying a mortality rate of 20-50%. Case presentation. Here we describe the case of an oldest old (84 years) woman, with severe cognitive impairment and immobilization syndrome attending our geriatric ward for aspiration pneumonia. During the fifth day of hospitalization, while pneumonia and respiratory symptoms were improving, tachycardia persisted (heart rate 130 bpm), associated with tremors and lack of sleep. The patient was affected by multinodular goiter and, a diagnosis of thyrotoxicosis was documented by elevated serum free thyroxine and free triiodothy-ronine levels (4.7 ng/dL and 6.6 ng/L, respectively), associated with undetectable thyroid-stimulating hormone (TSH 0.04 mIU/L), elevated urinary iodine excretion (849 µg/L) and normal serum thyroglobulin levels (10 ng/ mL).131I thyroid scan showed diffuse low uptake, suggesting iatrogenic thyrotoxicosis. The patient suffered from immobilization syndrome with bedsores that had been medicated twice a week with iodoform gauzes for one year. Prior to starting the use of iodoform dressings the patient was documented euthyroid. Conclusions. Over the past century, few cases have been described regarding possible severe toxicity caused by the use of iodoform gauzes, all of them presenting with neurovegetative symptoms as vomiting, altered sensor, which disappeared after withdrawn of the medication, but iatrogenic thyrotoxicosis was never demonstrated. Thus, to our knowledge, this is the first report documenting the onset of thyrotoxicosis induced by lasting use of iodoform gauzes.

Background ITALUNG is contributing to the European evaluation of low-dose CT (LDCT) screening for lung cancer (LC). Methods Eligible subjects aged 55–69 years, smokers or ex-smokers (at least 20 pack-years in the last 10 years), were randomised to receive an annual invitation for LDCT screening for 4 years (active group) or to usual care (control group). All participants were followed up for vital status and cause of death (at the end of 2014) and LC incidence (at the end of 2013). Pathological and clinical information was collected from the Tuscan Cancer Registry data. Results 1613 subjects were randomly assigned to the active group and 1593 to the control group. At the end of the follow-up period 67 LC cases were diagnosed in the active group and 71 in the control group (rate ratio (RR)=0.93; 95% CI 0.67 to 1.30). A greater proportion of stage I LC was observed in the active group (36% vs 11%, p Conclusions Despite the lack of statistical significance, the ITALUNG trial outcomes suggest that LDCT screening could reduce LC and overall mortality. Moreover, the comparison of the number of LC cases diagnosed in the two groups does not show overdiagnosis after an adequate follow-up period. A pooled analysis of all European screening trials is advocated to assess the benefit-to-harm ratio of LDCT screening and its implementation in public health settings. Trial registration number Results, NCT02777996.

We evaluated the possibility of improving detection of a dense intracranial artery on CT in acute stroke by narrowing window width, varying window level and performing a thin-slice helical scan for the circle of Willis, in some cases followed by postprocessing maximum-intensity projections. We carried out 32 examinations of 31 patients with a documented cerebral ischaemic attack, performing cranial CT within 6 h of the onset of symptoms. Patients with intracranial haemorrhage were excluded, as were patients who went on to thrombolytic therapy. Varying window width and centre level on standard 5 mm thick contiguous axial slices, we detected a dense proximal middle cerebral artery (MCA) in a higher proportion of patients. A 1.1 mm thick helical scan through the circle of Willis improved recognition of a dense distal horizontal segment and the temporoinsular branches of the MCA and of a dense posterior cerebral artery.

Lo studio della biforcazione carotidea con l'accurata valutazione del grado di stenosi appare di fondamentale importanza per l'approccio terapeutico al paziente con malattia cerebrovascolare aterosclerotica. Pur essendo ancor oggi l'angiografia considerata il «gold standard» nello studio della patologia carotidea, altre metodiche meno costose e non invasive, come l'Eco-Doppler e l'Angio-RM, sono state utilmente impiegate. La crescente diffusione di apparecchiature TC ad acquisizione volumetrica ha permesso lo sviluppo di una nuova metodica di imaging nello studio della biforcazione carotidea: angio-TC. Con tale metodica sono stati studiati 40 pazienti: ove è stato possibile sono stati confrontati i dati angio-TC con quelli di uno studio angiografico digitale, trovando una corrispondenza superiore all'80%.

A femoral neck fracture in an elderly patient often represents a major challenge for the orthopaedic surgeon who has to face not only the fracture, but also all the multiple issues related to age. Among others, malnutrition has been recognised as an important factor associated with severe aggravation in these patients. One-hundred-and-forty-seven patients were enrolled to investigate the use of two markers of patient nutritional status, i.e. serum albumin level and total leukocyte count (TLC), as predictors of mortality in the elderly patient suffering from proximal femur fracture. We found that low preoperative values of serum albumin and TLC proved to be directly related to worse outcomes. Therefore, these exams can be useful to identify patients with a femoral neck fracture that have higher risk of malnutrition and consequent higher mortality and that can benefit from some measures, such as albumin or protein nutritional supplement.

BackgroundPrevious studies have shown increased risk of fracture in older patients with poor or strict glycemic control (glycated hemoglobin, HbA1c, ≥ 8% or < 6-7% respectively); however, these reports did not investigate the oldest-old population. Comprehensive geriatric assessment (CGA) and a patient-centered approach have been proven to improve the quality of care in the management of Type 2 Diabetes Mellitus (T2DM) in the older patients, but data regarding T2DM in patients with fragility fractures are still lacking.AimTo investigate the prognostic role of HbA1c and frailty level in older diabetic patients admitted for hip fracture.MethodsProspective observational cohort study conducted on diabetic geriatric patients consecutively hospitalized for hip fracture in the orthogeriatric unit of a tertiary care hospital. Preoperative comprehensive geriatric assessment (CGA) was performed. Using the Clinical Frailty Scale (CFS), diabetic patients were categorized in robust (CFS < 5) and frail (CFS ≥ 5), and further stratified according to HbA1c values [Tertile 1 (T1) HbA1c < 48 mmol/mol, Tertile 2 (T2) 48-58 mmol/mol and Tertile 3 (T3) > 58 mmol/mol). Comparisons between continuous variables were performed with analysis of non-parametric test for independent samples, while relationships between categorical variables were assessed by chi-square test. Using logistic multivariate regression, we evaluated the determinants of 1-year all-cause mortality in diabetic older patients with hip fracture.ResultsAmong the 1319 older patients (mean age 82.8 ± 7.5 years, 75.9% females) hospitalized for hip fracture, 204 (15.5%) had a previous diagnosis of T2DM. T2DM patients showed an increased proportion of multiple concurrent fractures occurred during the accidental fall or syncope (12.7% vs 11.2%, p=0.02). One-year mortality after hip fracture surgery was significantly higher in T2DM as compared to not diabetic patients (21.2% vs 12.5%, pvs 5%, p=0.001 for T2 and 43.5% vs 13.3%, p=ConclusionsFrail patients with HbA1c ≥ 48 mmol/L showed an increased mortality risk as compared to robust counterparts. CFS represents an important tool to select diabetic subjects with higher likelihood of adverse outcome.

The aim of this single-center, open-label, randomized controlled study was to evaluate which formulation of vitamin D—between cholecalciferol and calcifediol—is most effective in the treatment of hypovitaminosis D in older adults. Demographic characteristics, clinical history, and comprehensive geriatric assessment were recorded at admission. Eligible patients were randomly assigned an equivalent vitamin D supplement, either with cholecalciferol or calcifediol, from the time of hospital admission to three months after discharge. Among the 140 older patients included (mean age 83 ± 6.6 years, 57.8% females), 69 received cholecalciferol and 71 received calcifediol. The mean plasma values of 25-hydroxyvitamin D3 (25OH-vitamin D3) found at the time of enrollment were 16.8 ± 9.9 ng/mL in patients receiving cholecalciferol and 18.8 ± 13.3 ng/mL in those treated with calcifediol (p = 0.31). At the three month follow-up, the mean concentration of 25OH-vitamin D3 was significantly higher in patients treated with calcifediol than in those receiving cholecalciferol (30.7 ± 8.4 vs. 45.4 ± 9.8 ng/mL, respectively; p < 0.001). Supplementation with either cholecalciferol or calcifediol effectively results in reaching the optimal circulating values of 25OH-vitamin D3 in older patients suffering from hypovitaminosis D. However, supplementation with calcifediol led to average circulating values of 25OH-vitamin D3 that were significantly higher (over 50%) than those obtained with cholecalciferol.

Hypothyroidism is characterized by increased thyrotropin (TSH) levels and reduced free thyroid hormone fractions while, subclinical hypothyroidism (sHT) by elevated serum TSH in the face of normal thyroid hormones. The high frequency of hypothyroidism among the general population in Western Countries made levothyroxine (LT4) one of the 10 most prescribed drugs. However, circulating TSH has been demonstrated to increase with aging, regardless the existence of an actual thyroid disease. Thus, when confronting an increase in circulating TSH levels in the elderly, especially in the oldest old, it is important to carry an appropriate diagnostic path, comprehensive of clinical picture as well as laboratory and imaging techniques. In the current review, we summarize the recommendations for a correct diagnostic workup and therapeutic approach to older people with elevated TSH value, with special attention to the presence of frailty, comorbidities, and poly-therapy. The treatment of choice for hypothyroid patients is hormone replacement with LT4 but, it is important to consider multiple factors before commencing the therapy, from the age dependent TSH increase to the presence of an actual thyroid disease and comorbidities. When treatment is necessary, a tailored therapy should be chosen, considering poly-pharmacy and frailty. A careful follow-up and treatment re-assessment should be always considered to avoid the risk of over-treatment. It is important to stress the need of educating the patient for a correct administration of LT4, particularly when poly-therapy is in place, and the importance of a tailored therapeutic approach and follow-up, to avoid overtreatment.

ObjectiveMicroRNAs (miRNAs) are small endogenous noncoding RNAs that pair with target messengers regulating gene expression. Changes in miRNA levels occur in thyroid cancer. Fine-needle aspiration (FNA) with cytological evaluation is the most reliable tool for malignancy prediction in thyroid nodules, but cytological diagnosis remains undetermined for 20% of nodules.DesignIn this study, we evaluated the expression of seven miRNAs in benign nodules, papillary thyroid carcinomas (PTCs), and undetermined nodules at FNA.MethodsThe prospective study included 141 samples obtained by FNA of thyroid nodules from 138 patients. miRNA expression was evaluated by quantitative RT-PCR and statistical analysis of data was performed. Genetic analysis of codon 600 of BRAF gene was also performed.ResultsUsing data mining techniques, we obtained a criterion to classify a nodule as benign or malignant on the basis of miRNA expression. The decision model based on the expression of miR-146b, miR-155, and miR-221 was valid for 86/88 nodules with determined cytology (97.73%), and adopting cross-validation techniques we obtained a reliability of 78.41%. The prediction was valid for 31/53 undetermined nodules with 16 false-positive and six false-negative predictions. The mutated form V600E of BRAF gene was demonstrated in 19/43 PTCs and in 1/53 undetermined nodules.ConclusionsThe expression profiles of three miRNAs allowed us to distinguish benign from PTC starting from FNA. When the assay was applied to discriminate thyroid nodules with undetermined cytology, a low sensitivity and specificity despite the low number of false-negative predictions was obtained, limiting the practical interest of the method.