Improving the TIR3B oncological stratification: try to bridge the gap through a comprehensive presurgical algorithm

PURPOSE

Indeterminate cytology still puzzles clinicians, due to its wide range of oncological risks. According to the Italian SIAPEC-IAP classification, TIR3B cytology holds up to 30% of thyroid cancer, which justifies the surgical indication, even if more than half of cases do not result in a positive histology. The study aim is to identify potential clinical, ultrasound or cytological features able to improve the surgical indication.

METHODS

Retrospective analysis. A consecutive series of TIR3B nodules referred to the Endocrine Unit of Careggi Hospital from 1st May 2014 to 31st December 2021 was considered for the exploratory analysis (Phase 1). Thereafter, a smaller confirmatory sample of consecutive TIR3B diagnosed and referred to surgery from 1st January 2022 to 31st June 2022 was considered to verify the algorithm (Phase 2). The main clinical, ultrasound and cytological features have been collected. A comprehensive stepwise logistic regression was applied to build a prediction algorithm. The histological results represented the final outcome.

RESULTS

Of 599 TIR3B nodules referred to surgery, 451 cases were included in the exploratory analysis. A final score > 14.5 corresponded to an OR = 4.98 (95% CI 3.24-7.65, p < 0.0001) and showed a PPV and NPV of 57% and 79%, respectively. The Phase 2 analysis on a confirmatory sample of 58 TIR3B cytology confirmed that a threshold of 14.5 points has a comparable PPV and NPV of 53% and 80%, respectively.

CONCLUSIONS

A predictive algorithm which considers the main clinical, US and cytological features can significantly improve the oncological stratification of TIR3B cytology.

Euthyroid sick syndrome as an early surrogate marker of poor outcome in mild SARS-CoV-2 disease

BACKGROUND

The new coronavirus 19 disease (COVID-19) represents the current worldwide emergency. According to past evidence, a simple biomarker, such as low free triiodothyronine (fT3) levels, within the framework of euthyroid sick syndrome (ESS), might help to identify patients with unfavourable outcomes.

OBJECTIVE

Evaluation of ESS significance in hospitalized mild COVID-19 patients.

DESIGN

Prospective study, from 1 April 2020 to 31 May 2021.

PARTICIPANTS

COVID-19 patients with mild disease at hospital admission.

MAIN MEASURES

At hospital admission, eligible patients underwent a complete thyroid function evaluation. Subjects with previous thyroid disease or with thyroid-interfering medications were excluded. Levels of fT3 were correlated to biochemical markers and to patient outcome, the latter considered as favourable in the event of infection recovery and unfavourable in the event of death or transfer to an intensive care unit (ICU).

KEY RESULTS

Of 600 screened patients, 506 were eligible for this study. Of those, 94 (19%) died during hospitalization and 80 (18%) required a transfer to ICU. The most frequent thyroid disorder was ESS (57%). Admission levels of fT3 were significantly lower within the unfavourable outcome subgroup (p < 0.001) and were negatively associated with several poor prognostic markers, including IL-6 (p < 0.001). In Kaplan-Meier and Cox regression analyses, fT3 was independently associated with poor outcome and death (p = 0.005 and p = 0.037, respectively). A critical fT3 threshold for levels < 2.7 pmol/l (sensitivity 69%, specificity 61%) was associated with a 3.5-fold increased risk of negative outcome (95%CI 2.34-5.34).

CONCLUSION

Low fT3 levels, in the framework of ESS, resulted as being a valid predictor of unfavourable outcomes in a very early stage population of COVID-19.

The use of head helmets to deliver noninvasive ventilatory support: a comprehensive review of technical aspects and clinical findings

A helmet, comprising a transparent hood and a soft collar, surrounding the patient’s head can be used to deliver noninvasive ventilatory support, both as continuous positive airway pressure and noninvasive positive pressure ventilation (NPPV), the latter providing active support for inspiration. In this review, we summarize the technical aspects relevant to this device, particularly how to prevent CO₂ rebreathing and improve patient–ventilator synchrony during NPPV. Clinical studies describe the application of helmets in cardiogenic pulmonary oedema, pneumonia, COVID-19, postextubation and immune suppression. A section is dedicated to paediatric use. In summary, helmet therapy can be used safely and effectively to provide NIV during hypoxemic respiratory failure, improving oxygenation and possibly leading to better patient-centred outcomes than other interfaces.

SETD2 and histone H3 lysine 36 methylation deficiency in advanced systemic mastocytosis

The molecular basis of advanced systemic mastocytosis (SM) is not fully understood and despite novel therapies the prognosis remains dismal. Exome sequencing of an index-patient with mast cell leukemia (MCL) uncovered biallelic loss-of-function mutations in the SETD2 histone methyltransferase gene. Copy-neutral loss-of-heterozygosity at 3p21.3 (where SETD2 maps) was subsequently found in SM patients and prompted us to undertake an in-depth analysis of SETD2 copy number, mutation status, transcript expression and methylation levels, as well as functional studies in the HMC-1 cell line and in a validation cohort of 57 additional cases with SM, including MCL, aggressive SM and indolent SM. Reduced or no SETD2 protein expression—and consequently, H3K36 trimethylation—was found in all cases and inversely correlated with disease aggressiveness. Proteasome inhibition rescued SETD2 expression and H3K36 trimethylation and resulted in marked accumulation of ubiquitinated SETD2 in SETD2-deficient patients but not in patients with near-normal SETD2 expression. Bortezomib and, to a lesser extent, AZD1775 alone or in combination with midostaurin induced apoptosis and reduced clonogenic growth of HMC-1 cells and of neoplastic mast cells from advanced SM patients. Our findings may have implications for prognostication of SM patients and for the development of improved treatment approaches in advanced SM.

Effects of sodium DL-lactate on insulin secretion in anesthetized dogs

The effect of sodium DL-lactate administration on insulin release in anesthetized dogs has been studied. Eleven mongrel dogs were infused with sodium DL-lactate for 20 min at the rate of 20 mg/kg . min. Lactate infusion produced simultaneous increases in blood glucose and plasma insulin levels in the pancreaticoduodenal vein. To determine whether lactate stimulated insulin secretion directly, sodium DL-lactate was rapidly injected into the pancreatic artery of six dogs; this pulse induced a significant increase in insulin release from pancreatic B-cells, even in the absence of a measurable change in blood glucose. Diazoxide, when infused in six dogs, blocked lactate-induced insulin secretion. These findings indicate that lactate, as do other circulating energy fuels, may play a role in the physiologic control of insulin secretion.

Studies on metabolic alterations after a mixed meal and during a 39-hour fast in thyrotoxicosis

In order to determine the endocrine and metabolic state of thyrotoxicosis we measured blood glucose and plasma insulin response to ingestion of a mixed meal in 19 euthyroid and 9 hyperthyroid subjects. Moreover concentrations of glucose, free fatty acids (FFA), glycerol, acetoacetate (AcAc) beta-hydroxybutyrate (beta-OHB), insulin and human growth hormone (hGH) were determined in the blood of both healthy and hyperthyroid patients after an overnight and a 39-h fast. In another group of thyrotoxics the overnight fasting respiratory quotient (RQ) was measured. After a mixed meal blood glucose and plasma insulin changes of FFA, AcAc and beta-OHB was significantly higher in thyrotoxics, whereas hGH increase did not appear significantly greater in these subjects. There was no statistical difference between the respiratory quotient mean values found in hyperthyroid and in control subjects. In conclusion, these data indicate that in thyrotoxicosis absolute insulin response to a mixed meal is normal and that food deprivation considerably increase lipid mobilization from adipose tissue and causes an exaggerated starvation ketosis. The RQ mean valoue suggests that in the hyperthyroid state lipid-derived fuel as well as carbohydrate-derived fuel contributes to the increased oxygen consumption.

Metabolic and endocrine responses to a standard mixed meal. A physiologic study

In order to study endocrine and metabolic responses to normal food ingestion, 8 'healthy' subjects received a standard mixed meal which reflected the composition of Western diet (CHO 47%, protein 23%, fat 26%, alcohol 4%), in 20 min. Before and after the meal, in each subject glucose, lactate, FFA, insulin, C-peptide, glucagon and HGH were determined. The results showed that glycemic and insulinemic responses were not very different from those observed after the classical oral glucose tolerance test. Plasma FFA and blood lactate decreased progressively after the meal. Plasma glucagon and HGH showed opposite changes: pancreatic glucagon rose and HGH slightly declined after composite food ingestion.