The current study does not confirm the recently reported usefulness of RTE in presurgical selection of nodules with indeterminate cytology and suggest the need for quantitative analytical assessment of nodule stiffness to improve RTE efficacy.

Context:The negative impact of subclinical hypothyroidism (sHT) on cardiovascular risk, widely recognized in young adults (aged Ͻ55-60 y), is still debated in the elderly (Ͼ65 y), especially in the oldest olds (Ͼ80 y).Evidence Acquisition: We searched Medline for reports published with the following search terms: "hypothyroidism," "subclinical hypothyroidism," "ageing," "elderly," "L-thyroxin," "thyroid," "guidelines," "treatment," "quality of life," "cardiovascular risk," "heart failure," "coronary heart disease" (CHD), "atherosclerosis," and "endothelial dysfunction." We limited our search to reports in English published after 1980, although we incorporated some reports published before 1980. We supplemented the search with records from personal files, textbooks, and relevant articles. Analyzed parameters included the epidemiology of thyroid failure, the effect of thyroid hormone on the aging process, cardiovascular function, and CHD risk factors. We also included the potential benefits of L-T 4 therapy on the quality of life, cardiovascular events, and survival.Evidence Synthesis: TSH levels increase with age, even in older people without thyroid disease. Most longitudinal studies show an increased risk for CHD events and mortality in sHT participants. This increase is less evident in the elderly, mainly in cases of serum TSH values above 10 mIU/L. Lower mortality rate in a cohort of the oldest olds (Ͼ85 y) has been reported. Conclusions: sHT in older people should be not regarded as a unique condition, and moderately old patients (aged Ͻ70 -75 y) could be considered clinically similar to the adult population, albeit with a higher optimal TSH target value. Conversely, the oldest old subjects should be carefully followed with a wait-and-see strategy, generally avoiding hormonal treatment. The decision to treat elderly people is still an unresolved clinical challenge-first, due to a lack of appropriately powered randomized controlled trials of L-T 4 in sHT patients, examining cardiovascular hard endpoints in various classes of age; and second, because of the negative effects of possible overtreatment. (J Clin Endocrinol Metab 98: 2256 -2266, 2013) S ubclinical hypothyroidism (sHT), defined as serum TSH concentration above the upper limit of the reference range in the face of normal free T 4 (FT 4 ) and free T 3 (FT 3 ) levels, is common in the elderly (1-3). This biochemical condition encompasses several pathological entities, mainly represented by chronic autoimmune thyroiditis even if increasing TSH may represent a physiological aging process (4).Depending on the degree of TSH elevation, sHT has been related to hyperlipidemia, intermediary metabolism changes, arterial hypertension, reduced glomerular filtration rate, and neuropsychiatric alterations (5-11). The negative impact of sHT in terms of coronary heart disease (CHD) and global cardiovascular (CV) risk is mostly acknowledged in young adults, whereas it remains to be established in the elderly, especially in the oldest old (aged Ͼ 80 y) (4). Moreover, t...

low T3 syndrome is very common in the hospitalised older population, emerging as the most sensitive independent predictor of short-term survival. Serum FT(3) determination should be included in the assessment of short-term prognosis of acutely ill older patients.

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 LT 4 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 LT 4 , particularly when poly-therapy is in place, and the importance of a tailored therapeutic approach and follow-up, to avoid overtreatment.

Overall, present results support a contribution for one-carbon metabolism to LOAD pathogenesis.