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Background: The discharge from the hospital of insulin-treated hyperglycemic patients is always challenging. This is even more so in patients requiring glucocorticoid treatment, such as those with COVID-19. Patients and Method: A retrospective monocentric study of 23 inpatients was conducted with newly diagnosed or already known diabetes mellitus (DM) who were naïve to insulin treatment, and who were hospitalized with COVID-19 in non-critical settings and then discharged. Patients were followed up for one month after discharge for the management of insulin treatment by a multi-professional team through phone consultations. Results: Insulin prescriptions at discharge were 24.6 ± 14 U/day injected in 2 ± 1.5 daily shots. A mean of three phone consultations was required. One month later, the mean insulin reduction was 1.5 ± 1.3 shots and 6 ± 5 U/day. All patients reached their glycemic target without hypoglycemic events, drop-outs, or readmissions. Conclusion: This study demonstrates the feasibility, efficacy, and safety of a multi-professional approach through telemedicine for managing DM patients after discharge during COVID-19.

Background. Primary hyperparathyroidism (PHPT) and thyroid diseases are a frequent concomitant occurrence, but the surgical approach to associated disease is still debated. Methods. We retrospectively evaluated a series of PHPT patients focusing on thyroid disease and surgery. Results. Among 238 PHPT patients undergoing parathyroidectomy (PTX) between 2002 and 2017, 128 were affected also by a benign thyroid disease, namely, goiter in 118 (76 multinodular (MNG) and 42 uninodular (UNG)), autoimmune thyroiditis in 10, and hyperthyroidism in 21. Surgical approach was unilateral neck exploration (UNE) in 59 patients and bilateral neck exploration (BNE) in 69. The PHPT cure rate was 94%. On comparing patients submitted to PTX only and PTX plus thyroidectomy (TX), in the latter MNG and hyperthyroidism were more frequent, and surgical time and length of stay were longer. No difference in surgical complications was found between patients undergoing UNE and BNE. Conclusion. PHPT patients with a concomitant thyroid disease underwent double surgery in almost two-thirds of the cases, mostly by BNE. The main factors driving the decision to perform concomitant PTX and TX were the presence of thyroid nodular disease with the nodule site ipsilateral to the presurgically localized parathyroid adenoma.

Use of salvage radiotherapy (SRT) after cancer surgery has a low disease control rate. Low prostate-specific antigen (PSA) levels in the blood pre-SRT seem to be the best predictor of success. Our study used PSA monitoring during and after treatment to investigate if PSA levels during SRT can give further information about its chances of success. In a retrospective cohort of 78 patients submitted to salvage radiotherapy (SRT) for biochemical relapse after cancer surgery, we assess PSA values at start of the treatment, 1 week before the end of treatment, and every 3 months for at least 2 years. Post-treatment PSA in our series and the systematic review of the literature aimed to investigate the prognostic value of PSA variation for biochemical disease-free survival. The results suggest that a decline in PSA levels after at least 45 Gy of radiation therapy dosage or a decrease of at least 0.2 ng/mL compared with the start value may be a favorable prognostic factors for biochemical disease-free survival. These results need confirmation using prospective data before being applied to clinical practice and could help physician to choose the correct therapeutic strategy.

Objective: To evaluate calcitonin (CT) levels in sporadic primary hyperparathyroidism (PHPT), which has to date rarely been considered. Methods: We evaluated serum CT levels in 290 consecutive patients with sporadic PHPT at diagnosis. Results: Mild elevations in CT levels (hyperCT) were found in 25 patients (8.6%), with no correlation among the demographic, clinical, and biochemical findings. In addition, no differences were found between patients with and without hyperCT. Follow-up data were available for 19/25 patients, but CT values were only available for 10. CT normalized in all surgically cured patients regardless of the extent of the surgery (parathyroidectomy [PTX] only in 8 and associated with partial or total thyroidectomy for benign nodular goiters in 7). Conclusion: hyperCT is an uncommon feature of sporadic PHPT and not related to biochemical or clinical features of the disease. In addition, hyperCT is reversible after PTX, regardless of whether concomitant thyroidectomies have been conducted. Abbreviations: CT = calcitonin; eGFR = estimated glomerular filtration rate; hyperCT = hypercalcitoninemia; MEN = multiple endocrine neoplasm; MTC = medullary thyroid carcinoma; PHPT = primary hyperparathyroidism; PPI = proton pump inhibitor; PTH = parathyroid hormone; PTX = parathyroidectomy

Background Although the inverse correlation between serum PTH and phosphate (P) levels in patients with primary hyperparathyroidism (PHPT) is well known, the relationship between P levels and the clinical picture of the disease has not been well investigated. This was thus the aim of this paper. Patients A total of 472 consecutive patients with PHPT attending our center were retrospectively evaluated at diagnosis. Results P levels lower than 2.5 mg/dL (HypoP) were found in 198/472 patients (41.9%). HypoP was mild (2-2.5 mg/dL), moderate (1-1.9 mg/dL), and severe ( Conclusions We observed a relationship between P levels and biochemical and clinical features of PHPT severity. In asymptomatic PHPT patients, even moderate HypoP is predictive of surgical indication, regardless of age and hypercalcemia severity.

Background The clinical presentation of primary hyperparathyroidism (PHPT) has changed greatly during the past few decades. Our aim was to evaluate whether the clinical presentation at diagnosis differed according to age. Methods We evaluated retrospectively a monocentric series of 462 consecutive patients with PHPT, dividing them according to a cutoff of 65 years of age. Results No differences were found in the mean serum PTH, calcium, or vitamin D levels. In older patients (n = 212; 45.9%), the urinary calcium levels were significantly lower (median, 205 mg/24 hour; interquartile range, 220 mg/24 hour) compared with those in younger patients (median, 308 mg/24 hour; interquartile range, 233 mg/24 hour). In addition, renal involvement was significantly less frequent (25% vs 49.2%), and bone involvement significantly more frequent (58% vs 44%) in older patients compared with younger patients. The clinical presentation was significantly different between the two age groups, with a lower frequency of symptomatic forms and a greater frequency of asymptomatic forms not meeting surgical criteria in the older patients (44.4% vs 57.2% and 18.4% vs 5.6%, respectively). Osteoporosis was significantly more frequent in the older adults than in their younger counterparts. The most affected bone site was the forearm in older adults and the lumbar spine in younger ones (50.3% and 50.5%, respectively). Conclusion The clinical presentation of PHPT differs according to age, and this difference can affect the selection of management modalities.

Objective There is a direct bidirectional link between parathyroid hormone (PTH) and the renin-angiotensin-aldosterone system (RAAS), but few studies evaluated the RAAS in patients with primary hyperparathyroidism (PHPT), mainly biased from concomitant antihypertensive treatment. Methods We retrospectively evaluated a consecutive series of 130 normotensive patients with PHPT comparing aldosterone (ALD) levels and plasma renin activity (PRA) with the demographic, biochemical, or clinical features of PHPT. Results No correlation was found between ALD and PRA, and the demographic, biochemical, and bone densitometry parameters in patients with PHPT without hypertension, with the exception of a negative correlation between age and serum PRA. Moreover, there was no significant correlation between PTH and ALD levels even in patients whose PTH level was >100 ng/L (P = .088). Conclusion In our normotensive patients with PHPT, the ALD, PRA, and aldosterone/renin ratio were not correlated to PTH and calcium levels. In addition, they were neither related to PHPT clinical presentation nor renal function, vitamin D status, bone mass loss, or the presence of comorbidities such as diabetes and obesity. Further studies are needed to clarify the complex interplay between PTH and the RAAS in the modern PHPT presentation.

Background About a third of patients who underwent radical prostatectomy for prostate cancer (Pca) develop a biochemical failure (BF) within 10 years from surgery, and about a half of them receive salvage radiation therapy (SRT). Factors to predict risk to relapse after SRT are still lacking. Dynamic models, based on the assessment of changes in Prostate Specific Antigen (PSA) postsurgery seem to show good reliability. Aims The goal of the study was to identify a simple analytical method for the postsalvage radiation therapy biochemical failure (post-SRTBF) prediction before the end of the SRT, regardless of the PSA value at the beginning of the treatment (PSA start), measuring the PSA values at the start and 1 week before the end of SRT. Methods In a series of 83 patients treated with SRT for BF of Pca we measured PSA values at the first day and 1 week before the end of SRT. These values were used to define an analytical method for the post-SRTBF prediction. Results PSA value in patients without post-SRTBF show a significant difference in term of difference during the SRT with respect to patients with post-SRTBF. Starting from this difference, we identified a simple and practical analytical method for the post-SRTBF prediction before the end of the SRT. The data corresponds with the model and the analytical method is highly predictive (Sensitivity = 81%, Specificity = 85%, Accuracy = 83%). Conclusion This study offers a new tool to early predict Pca relapse overtime and to select patients who can benefit from an early additional systemic treatment.

Introduction:Stereotactic body radiation therapy is increasingly used in the treatment of early-stage lung cancers. Guidelines provide indications regarding the constraints to the organs at risk (OARs) and the minimum coverage of the planning target volume but do not suggest optimal dose distribution. Data on dose distribution from the different published series are not comparable due to different prescription modalities and reported dose parameters.Methods:We conducted a review of the published data on dose prescription, focusing on the role of homogeneity on local tumor control, and present suggestions on how to specify and report the prescriptions to permit comparisons between studies or between cases from different centers.Conclusions:To identify the dose-prescription modality that better correlates with oncologic outcomes, future studies should guarantee a close uniformity of dose distribution between cases and complete dose parameters reporting for treatment volumes and OARs.

The clinical presentation of primary hyperparathyroidism (PHPT) has changed widely in developed countries in the last few decades. We evaluated its variations in our series over a 20-year period (i.e., 1997-2016).A retrospective survey was conducted in our series of 364 well-characterized consecutive patients, arbitrarily divided into 4 consecutive 5-year periods at diagnosis.In the overall series, only estimated glomerular function (eGFR) and urinary calcium (UCa) showed a significant upward trend ( P = .032 and .039, respectively), whereas demographic and clinical characteristics were stable. The UCa upward trend was also confirmed for the subgroup of symptomatic patients ( P = .013). No difference was observed in the demographic, clinical, or biochemical characteristics of asymptomatic patients or in the fraction of patients meeting surgical criteria.The clinical presentation of PHPT was stable over 20 years in our large series.Ca = calcium; eGFR = estimated glomerular filtration rate; 25OHD = 25-hydroxyvitamin D; PHPT = primary hyperparathyroidism; PTH = parathyroid hormone; UCa = urinary calcium.

Primary hyperparathyroidism (PHPT) and thyroid diseases are highly prevalent in the general population, but the putative link between the 2 conditions remains unclear.A monocentric consecutive series of 434 patients with PHPT was retrospectively evaluated by lab and ultrasonography to look for thyroid abnormalities. Patients were classified in 3 groups: without thyroid abnormalities (group 1, n = 171), with thyroid diseases not previously known (group 2a, n = 69), and thyroid diseases previously known (group 2b, n = 194).In terms of thyroid disease, no significant difference was found between groups 2a and 2b, except for the significantly larger number of patients with toxic nodular goiter in group 2b. PHPT was more frequently symptomatic in group 2a than in group 2b, despite no differences in serum calcium, creatinine, parathyroid hormone (PTH), or 25-hydroxyvitamin D (25OHD) levels.A total of 60% of PHPT patients had a thyroid disease that was unknown prior to PHPT diagnosis in almost one-third of cases. The newly diagnosed and previously known thyroid diseases were similar, both mostly affecting postmenopausal females.Ab = antibody; aPHPT = asymptomatic PHPT; 25OHD = 25-hydroxyvitamin D; PHPT = primary hyperparathyroidism; PTH = parathyroid hormone; Tg = thyroglobulin; TPO = thyroperoxidase; TSH = thyroid-stimulating hormone; US = ultrasound.

To evaluate the basal/total ratio of daily insulin dose (b/T) in outpatients with diabetes type 1 (DM1) and type 2 (DM2) on basal-bolus regimen, by investigating whether there is a relationship with HbA1c and episodes of hypoglycemia.Multicentric, observational, cross-sectional study in Italy. Adult DM1 (Total daily insulin dose was significantly higher in DM2 patients (52.3 ± 22.5 vs. 46 ± 20.9 U/day), but this difference disappeared when insulin doses were normalized for body weight. The b/T ratio was lower than 0.50 in both groups: 0.46 ± 0.14 in DM1 and 0.43 ± 0.15 in DM2 patients (The b/T ratio was independent of glycemic control and incidence of hypoglycemia.

When using an electronic portal imaging device (EPID) for dosimetric verifications, the calibration of the sensitive area is of paramount importance. Two calibration methods are generally adopted: one, empirical, based on an external reference dosimeter or on multiple narrow beam irradiations, and one based on the EPID response simulation. In this paper we present an alternative approach based on an intercalibration procedure, independent from external dosimeters and from simulations, and is quick and easy to perform. Each element of a detector matrix is characterized by a different gain; the aim of the calibration procedure is to relate the gain of each element to a reference one. The method that we used to compute the relative gains is based on recursive acquisitions with the EPID placed in different positions, assuming a constant fluence of the beam for subsequent deliveries. By applying an established procedure and analysis algorithm, the EPID calibration was repeated in several working conditions. Data show that both the photons energy and the presence of a medium between the source and the detector affect the calibration coefficients less than 1%. The calibration coefficients were then applied to the acquired images, comparing the EPID dose images with films. Measurements were performed with open field, placing the film at the level of the EPID. The standard deviation of the distribution of the point‐to‐point difference is 0.6%. An approach of this type for the EPID calibration has many advantages with respect to the standard methods — it does not need an external dosimeter, it is not related to the irradiation techniques, and it is easy to implement in the clinical practice. Moreover, it can be applied in case of transit or nontransit dosimetry, solving the problem of the EPID calibration independently from the dose reconstruction method. PACS number: 87.56.‐v

Objectives The presence of prostate-specific antigen (PSA)-bounce after external beam radiation therapy (EBRT) and hormone therapy (HT) makes PSA an unreliable marker in determining PSA biochemical failure (PSA-BF) during the first 2 years after EBRT + HT in patients with non-operated prostate cancer (CaP). To determine the reliability of PSA-BF in predicting clinical outcomes, the Kamat definition, which does not consider PSA-BF during the first 24 months after EBRT, was tested against three other more frequently used methods (American Society of Radiation Oncology, Vancouver, and American Society of Radiation Oncology-Phoenix), which do. Secondly, their relative accuracies in predicting the clinical outcomes were also calculated. Materials and methods In January 2011, 193 consecutive CaPs, treated with radical EBRT + HT in our institution from 1999 to 2002, were retrospectively investigated. BF was calculated according to the Kamat definition against the other three above-mentioned methods. Each BF-free survival was analyzed in function of every clinical endpoint (clinical-failure-free survival, cause specific survival, and overall survival) using univariate and multivariate Cox regression analyses. The accuracy of each definition in predicting clinical relapse was also calculated and compared. Results Only the Kamat BF definition had both a significant Cox hazard ratio, regarding clinical events or cancer deaths, and the best accuracy values in predicting clinical outcomes. Retrospective study design was the major limitation of the study. Conclusions Only the Kamat definition, which does not consider PSA-BF during the first 24 months after EBRT + HT, was shown to be a reliable predictor of clinical events. Thus, our results suggest that solely PSA-based BF should not be considered as a reliable surrogate endpoint during the first 24 months after EBRT + HT. Consequently, caution should be used in adopting rescue treatment without further work-up on an individual basis.