Outcome of Sars-COV-2-related thyrotoxicosis in survivors of Covid-19: a prospective study

PURPOSE

To evaluate the post- coronavirus disease-19 (COVID-19) outcome of thyroid function in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related thyrotoxicosis.

METHODS

This was a single-center prospective study involving 29 patients (11 females, 18 males; median age 64 years, range: 43-85) with thyrotoxicosis diagnosed after hospitalization for COVID-19 and then followed-up for a median period of 90 days (range: 30-120) after hospital discharge. At follow-up, patients were evaluated for serum thyrotropin (TSH), free-thyroxine (FT4), free-triiodiothyronine (FT3), TSH receptor antibodies (TRAb), thyroglobulin antibodies (TgAb), thyroperoxidase antibodies (TPOAb) and ultrasonographic thyroid structure.

RESULTS

After recovery of COVID-19, serum TSH values significantly increased (P < 0.001) and FT4 values significantly decreased (P = 0.001), without significant change in serum FT3 (P = 0.572). At follow-up, 28 subjects (96.6%) became euthyroid whereas overt hypothyroidism developed in one case. At the ultrasound evaluation of thyroid gland, hypoecogenicity was found in 10 patients (34.5%) and in these cases serum TSH values tended to be higher than those without thyroid hypoecogenity (P = 0.066). All subjects resulted to be negative for TgAb, TPOAb and TRAb.

CONCLUSION

In a short-term follow-up, thyroid function spontaneously normalized in most subjects with SARS-CoV-2-related thyrotoxicosis. However, thyroid hypoecogenicity was found in a remarkable number of them and future longer-term studies are needed to clarify whether this ultrasonographic alteration may predispose to develop late-onset thyroid dysfunction.

Vaccine-preventable diseases screening and vaccination programs for healthcare professions students

Background

Students in Healthcare Professions (SHPs) present an increased risk of contracting and transmitting Vaccine-Preventable Diseases (VPDs). Our study aimed to investigate the organizational strategies (screening and immunization for VPDs and vaccination promotion among SHPs) implemented by the healthcare facilities accredited with the University of Milan.

Methods

we sent an e-survey by e-mail to medical residents and first- and last-year students in nursing, midwifery and healthcare assistance.

Results

among 3397 invited SHPs, 645 participated. We included in the analysis 522 SHPs, distributed in 24 facilities across the Lombardy region (mean age 27,4 years; 69,5% female; 69% medical residents, 28% nursing, 2% healthcare assistance, and 1% midwifery students). Although most participants underwent occupational health visit before the traineeship start (47,5%) or within 6 months (29,5%), others hadn't undergone yet (15,1%). The visits included the collection of vaccination history (72,6%; 64,6% from written documentation), serological tests for VPDs (hepatitis B 76,1%, measles and rubella 58,4%, varicella 54,4%), and screening for latent TB (69,7%). Vaccinations were recommended to 226 participants, but only 173 fully (76,5%) or partially (8%) complied. Full compliance was associated with nudges like in-hospital (Chisq. 18,7; p = 0.00) and free vaccinations (Chisq. 31; p = 0.00). Reported facility vaccination policies included campaigns (posters 37,4%, intranet 39,5%, social media 11,5%, general/personalized letters 30,3%/11,5%), time-off incentives (7,7%), on-site (30,5%) and opinion leaders' vaccinations (9,8%). However, SHPs were often unaware of those strategies (mean 48,6%), and intra-facility answers were sometimes discordant (agreement &lt;70% for facilities with &gt;30 respondents).

Conclusions

SHPs are often unaware or discordant regarding vaccination policies carried out by traineeship facilities, suggesting the need of inclusive communication strategies.

Key messages

About half of students in healthcare professions are screened for VPDs after the start of the traineeship. Students in healthcare professions are often unaware of vaccination promotion strategies.

Traffic noise, air pollutants and incidence of diabetes mellitus: a population cohort study in Milan

Background

Recent evidence suggests a link between long-term exposure to traffic-related pollution and incidence of type 2 diabetes mellitus, a leading cause of morbidity and mortality in adults. The present study aims at exploring this association in a highly urbanized setting such as the city of Milan.

Methods

This is a population-based retrospective dynamic cohort study in the municipality of Milan. All residents aged &gt;35 years with no prior diagnosis of diabetes were included (N = 1096654), with follow-up ranging from January 2011 to June 2019. The residential address of each subject was geocoded and assigned mean values of traffic noise at the day-evening-night level (Lden, dB) and NO2 concentration (µg/m3) using a noise predictive model and a NO2 land-use regression model with 30x30 m grid resolution. Associations with a new diagnosis of diabetes were assessed with Cox proportional hazards models adjusted for age, sex, nationality and a socio-economic deprivation index. A dichotomous classification of addresses as city center/suburban based on the External Ring Road as a delimiter was also used for a stratified analysis.

Results

New diagnoses of diabetes occurred in 26134 subjects (2.4%). Models using NO2, either continuous or ranked into quintiles, yielded no significant results. When using noise to categorize traffic intensity (&lt;65/65-69/70-74/≥75 dB), a positive yet non-significant trend was shown. At stratified analysis, increases in risk were found for the two highest levels of exposure in the city center (70-74 dB: HR 1.141, 95% C.I. 1.013-1.284; ≥75 dB: HR 1.185, 95% C.I. 1.058-1.328).

Conclusions

Residential proximity to high-traffic roads categorized according to traffic noise was found to be associated with an increased risk of being diagnosed with diabetes. The effect is evident in the city center, whereas in the suburban area it might be masked by individual and lifestyle factors that ought to be investigated in future studies.

Key messages

Living close to high-traffic roads in a highly urbanized environment increases the risk of diabetes. Policies aimed at reducing traffic intensity in large cities may lower the incidence of this highly prevalent chronic condition.

Traffic-borne pollution as a risk factor for acute vascular events: a population study in Milan

Background

Traffic-borne noise and air pollution have both been associated with cardiovascular and cerebrovascular diseases, albeit with inconsistent findings and issues of collinearity/mutual confounding. The present study aims at evaluating the role of long-term exposure to traffic-borne pollution as a risk factor for acute vascular events in a highly urbanized setting.

Methods

This is a population-based retrospective dynamic cohort study including all residents aged &gt;35 years in the municipality of Milan over the years 2011-2018 (N = 1087110). A noise predictive model and a NO2 land-use regression model were used to assign mean values of traffic noise at the day-evening-night level (Lden, dB) and NO2 concentration (µg/m3) to the residential address of each subject. Cox proportional hazards models were performed to assess the incidence of acute vascular events, with adjustment for potential confounders (age, sex, nationality, a socio-economic deprivation index) and sub-analyses for different outcomes (acute myocardial infarction, ischemic stroke, hemorrhagic stroke).

Results

A total of 27282 subjects (2.5%) had an acute vascular event. Models using NO2 yielded inconsistent results. When using Lden as a proxy of traffic intensity, there was a positive trend in risk with increasing levels of exposure, with an optimal cut-off for dichotomization set at 70 dB (HR 1.025, 95% C.I. 1.000-1.050). The association was observed specifically for ischemic stroke (HR 1.043, 95% C.I. 1.003-1.085) and hemorrhagic stroke (HR 1.036, 95% C.I. 0.969-1.107). When stratifying by age group and sex, a remarkable effect was found for hemorrhagic stroke in men aged &lt;60 (HR 1.439, 95% C.I. 1.156-1.792).

Conclusions

Living close to high-traffic roads was found to exert a small but tangible effect on the risk of stroke. The varying effects observed for specific outcomes and in different age and sex groups are likely due to different pathogenetic mechanisms at play, which warrant further investigation.

Key messages

Residential proximity to roads with high traffic intensity (mean traffic noise level over 70 dB) is a risk factor for stroke, especially for hemorrhagic stroke in middle-aged men. Further interventions aimed at reducing traffic intensity in highly urbanized cities may be justified in order to reduce morbidity and mortality from stroke.

Accuracy of Humanitas Ultrasound Criteria in Assessing Disease Activity and Severity in Ulcerative Colitis: A Prospective Study

BACKGROUND

Colonoscopy [CS] is the standard for assessing disease activity in ulcerative colitis [UC], although invasive and poorly tolerated. Bowel ultrasound [BUS] may be a valid alternative in UC patients; however, the comparative accuracy between BUS and CS is unknown.

METHODS

Consecutive patients with UC were prospectively assessed by CS and BUS. Colonic wall thickening [CWT >3 mm], colonic wall flow at power Doppler [CWF], colonic wall pattern [CWP], and presence of lymph nodes evaluated at BUS were compared with CS. The endoscopic activity was assessed according to the Mayo endoscopic sub-score [0-3]. All BUS investigations were performed by two independent gastroenterologists and the kappa statistic for agreement was calculated. Ultrasonography-based criteria (Humanitas Ultrasound Criteria [HUC]) were developed.

RESULTS

A total of 53 UC patients [56% with left-sided colitis, 19% with pancolitis] were prospectively enrolled. Of these, 22 patients had mucosal healing [Mayo endoscopic sub-score 0-1] and 31 patients were in endoscopic activity. CWT, CWF, hypoechogenic CWP and the presence of lymph nodes significantly correlated with endoscopic activity [p < 0.05]. CWT [p = 0.01] and CWF [p = 0.09] were independent predictors for endoscopic activity. The HUC developed are: [i] the presence of a CWF and CWT > 3 mm; or [ii] the absence of a CWF and CWT > 4.43 mm. They showed high accuracy for the detection of disease activity [sensitivity 0.71, specificity 1.00]. The interobserver agreement for BUS was excellent [kappa 0.86].

CONCLUSIONS

BUS is a non-invasive, easy-to-use tool to manage UC patients in clinical practice. HUC were very accurate in assessing disease activity in UC patients.

[18F]FDG-PET/CT texture analysis in thyroid incidentalomas: preliminary results

Background

significance of incidental thyroid 2-deoxy-2-[¹⁸F]fluoro-D-glucose ([¹⁸F]FDG) uptake on positron emission tomography/computed tomography (PET/CT) scans remains controversial. We aimed to evaluate the ability of [¹⁸F]FDG-PET/CT texture analysis to predict final diagnosis in thyroid incidentaloma.

Methods

We retrospectively evaluated medical records of all patients who performed a [¹⁸F]FDG-PET/CT from January 2012 to October 2016. Those patients who presented a thyroid incidentaloma described in the medical records and performed a fine needle aspiration in our institution were considered for the analysis. Cytological and/or histological results were used as reference standard to define the final diagnosis. In case of negative cytology, the nodule was considered benign. In case of non-diagnostic or inconclusive results ultrasound, follow-up and further cytology/histology were used as final diagnosis. For suspected or positive cytological result, histology was used as reference standard. PET images were segmented using a General Electric AW workstation running PET VCAR software (GE Healthcare, Waukesha, WI, USA) settled with a threshold of 40% SUV_max. LifeX software (http://www.lifexsoft.org) was used to perform texture analysis. Statistical analysis was performed with R package (https://www.r-project.org).

Results

We identified 55 patients with incidental thyroid [¹⁸F]FDG uptake. Five patients were excluded from the analysis because a final diagnosis was not available. Thirty-two out of 50 patients had benign nodules while in 18/50 cases a malignancy (primary thyroid cancer = 15, metastases = 3) was diagnosed. Conventional PET parameters and histogram-based features were calculated for all 50 patients, while other matrices-based features were available for 28/50 patients. SUV_max and skewness resulted significantly different in benign and malignant nodules (p = 0.01 and = 0.02, respectively). Using ROC analysis, seven features were identified as potential predictors. Among all the textural features tested, skewness showed the best area under the curve (= 0.66). SUV-based parameters resulted in the highest specificity while MTV, TLG, skewness and kurtosis, as well as correlation_GLCM resulted better in sensitivity.

Conclusions

[¹⁸F]FDG-PET/CT texture analysis seems to be a promising approach to stratify the patients with thyroid incidentaloma identified on PET scans, with respect to the risk of the diagnosis of a malignant thyroid nodule and thus, could refine the selection of the patients to be referred for cytology.

Surgical sentinel lymph node biopsy in early breast cancer. Could it be avoided by performing a preoperative staging procedure? A pilot study

Background

The aim of this pilot trial was to study the feasibility of sentinel node percutaneous preoperative gamma probe-guided biopsy as a valid preoperative method of assessment of nodal status compared to surgical sentinel lymph node biopsy.

Material/Methods

This prospective study enrolled 10 consecutive patients without evidence of axillary lymph node metastases at preoperative imaging. All patients underwent sentinel node occult lesion localization (SNOLL) using radiotracer intradermic injection that detected a “hot spot” corresponding to the sentinel node in all cases. Gamma probe over the skin detection with subsequent ultrasonographically guided needle biopsy of the sentinel node were performed. The percutaneous needle core histopathological diagnosis was compared to the results of the surgical biopsy.

Results

Preoperative sentinel node identification was successful in all patients.

Conclusions

The combination of preoperative gamma probe sentinel node detection and ultrasound-guided biopsy could represent a valid alternative to intraoperative sentinel node biopsy in clinically and ultrasonographically negative axillary nodes, resulting in shorter duration of surgery and lower intraoperative risks.

[Giant fibroadenoma of the breast. Its clinical picture and differential diagnosis. A report of a clinical case]

An 18-year-old girl came to our Institute with a large tumefaction at the right breast, that during the last year had risen slowly but continuously. She underwent some clinical and instrumental exams that allow us to diagnose a giant adenofibroma or cystosarcoma phyllodes without excluding either of them. Then she undergoes a subcutaneous mastectomy with an application of a prosthesis. From the histologic point of view it is a giant adenofibroma. Giant adenofibroma is a rare breast pathology, always benign. Nowadays we have some difficulties distinguishing it from cystosarcoma phyllodes, which has both a benign and malignant form. It is important to distinguish the two pathologies before operation as they have a different therapeutic approach and a different follow-up. Cystosarcoma phyllodes can in fact relapse and when malignant can cause metastasis.