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British Journal of Anaesthesia Dec 2021Thyroid storm is a feared complication in patients with hyperthyroidism undergoing surgery. We assessed the risk of thyroid storm for different preoperative treatment...
BACKGROUND
Thyroid storm is a feared complication in patients with hyperthyroidism undergoing surgery. We assessed the risk of thyroid storm for different preoperative treatment options for patients with primary hyperthyroidism undergoing surgery.
METHODS
Pubmed, EMBASE, and The Cochrane Library were searched systematically for all studies reporting on adult hyperthyroid patients undergoing elective surgery under general anaesthesia. Selected studies were categorised based on preoperative treatment: no treatment, antithyroid medication (thionamides), iodine, β-blocking medication, or a combination thereof. Treatment effect, that is restoring euthyroidism, was extracted from the publications if available. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) or the Cochrane Risk of Bias tool for randomised studies.
RESULTS
The search yielded 7009 articles, of which 26 studies published between 1975 and 2020 were selected for critical appraisal. All studies had moderate to critical risk of bias, mainly attributable to risk of confounding, classification of intervention status, and definition of the outcome. All studies reported on thyroidectomy patients. We found no randomised studies comparing the risk of thyroid storm between treated and untreated patients. Cases of thyroid storm were reported in all treatment groups with incidences described ranging from 0% to 14%.
CONCLUSION
Evidence assessing the risk of perioperative thyroid storm is of insufficient quality. Given the seriousness of this complication and the impossibility of identifying patients at increased risk, preoperative treatment of these patients remains warranted.
Topics: Humans; Hyperthyroidism; Perioperative Period; Preoperative Care; Risk Assessment; Surgical Procedures, Operative; Thyroid Crisis
PubMed: 34389171
DOI: 10.1016/j.bja.2021.06.043 -
Annals of Medicine and Surgery (2012) Sep 2022Thyrotoxicosis is a clinical syndrome produced by a multitude of disorders. Thyrotoxicosis is a serious medical condition that, if left untreated, can lead to a fatal... (Review)
Review
BACKGROUND
Thyrotoxicosis is a clinical syndrome produced by a multitude of disorders. Thyrotoxicosis is a serious medical condition that, if left untreated, can lead to a fatal illness. This review of recent evidences give additional input for perioperative management of thyrotoxic patients.
METHODS
The literatures were found with Boolean operators in the form of thyrotoxicosis AND anesthesia, antithyroid medications AND perioperative optimization AND beta blockers OR calcium channel blockers in electronic data base sources such as the Cochrane library, PubMed, and Google scholar. This review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.
CONCLUSIONS
and recommendations: Before surgery and anesthesia, manifestation of thyrotoxicosis including palpitation, irritability etc should be ruled out.
PubMed: 36147169
DOI: 10.1016/j.amsu.2022.104487 -
Brain Sciences Nov 2022Thyroid hormone (TH) augmentation, although commonly used for major depression, is sparingly used for bipolar disorder (BD) after the failure of mood-stabilizing agents.... (Review)
Review
Thyroid hormone (TH) augmentation, although commonly used for major depression, is sparingly used for bipolar disorder (BD) after the failure of mood-stabilizing agents. While the exact mechanisms of thyroid hormone action in BD remains unclear, central thyroid hormone deficit has been postulated as a mechanism for rapid cycling. This systematic review-conducted in accordance with the PRISMA guidelines-of eight studies synthesizes the evidence for TH augmentation in BD. A systematic search of the Ovid MEDLINE, Embase, PsycINFO, and Cochrane databases was conducted for randomized controlled trials (RCT), open-label trials, and observational studies of levothyroxine (LT4) and triiodothyronine (T3) for BD. Open-label studies of high dose LT4 augmentation for bipolar depression and rapid cycling showed improvement in depression outcomes and reduction in recurrence, respectively. However, an RCT of high-dose LT4 did not show benefit in contrast to placebo. An RCT comparing LT4, T3, and placebo showed benefit only in rapid-cycling bipolar women. A meta-analysis could not be completed due to significant differences in study designs, interventions, and outcomes. Our systematic review shows mixed evidence and a lack of high-quality studies. The initial promise of supratherapeutic LT4 augmentation from open-label trials has not been consistently replicated in RCTs. Limited data are available for T3. The studies did not report significant thyrotoxicosis, and TH augmentation were well tolerated. Therefore, TH augmentation, especially with supratherapeutic doses, should be reserved for highly treatment-resistant bipolar depression and rapid-cycling BD.
PubMed: 36421864
DOI: 10.3390/brainsci12111540 -
Frontiers in Endocrinology 2023To probe the appropriate iodine nutritional status for patients with Graves'disease (GD) hyperthyroidism and on antithyroid drugs (ATD) or after drugwithdrawal. (Review)
Review
AIM
To probe the appropriate iodine nutritional status for patients with Graves'disease (GD) hyperthyroidism and on antithyroid drugs (ATD) or after drugwithdrawal.
METHOD
Studies were retrieved from three databases (Embase, Medline, and Cochrane Library) and were screened and evaluated using predefined criteria. The risk of bias of each trial was assessed using a tool from Cochrane. The iodine nutritional status of the subjects was redefined according to the World Health Organization (WHO) criteria and classified as insufficient/adequate/above requirements/excessive iodine intake.
RESULT
Two randomized controlled trials (RCTs) and 3 observational studies were selected from the 376 retrieved papers, which had different degrees of risk of bias in study design. The heterogeneity among them prevented us from further synthesizing effect indicators and subsequent statistical analyses. Two RCTs with high quality showed that insufficient or above requirements iodine intake was detrimental for ATD-treated GD patients; adequate iodine intake was associated with a lower risk of recurrence and better efficacy in controlling thyrotoxicosis. It could be speculated from three low-quality observational studies that excessive iodine intake may be associated with higher (or similar) recurrence rates and lower remission rates compared to above requirements iodine intake in these patients, but none of them could answer the question of the effect of insufficient or adequate iodine intake on this issue.
CONCLUSION
Although the available evidence is suboptimal, this systematic review tentatively suggests that in adult patients with GD hyperthyroidism receiving ATDs and according to WHO criteria for iodine nutritional status, adequate iodine intake is associated with a lower recurrence rate, a higher remission rate and a better efficacy to control thyrotoxicosis than insufficient, above requirement, or excessive iodine intake. Future RCTs with large samples are expected to elucidate the actual impact of different iodine nutritional statuses on the recurrence rate of hyperthyroidism and the efficacy of ATD to control thyrotoxicosis in these patients.
SYSTEMATIC REVIEW REGISTRATION
identifier CRD42022359451.
Topics: Humans; Adult; Antithyroid Agents; Iodine; Nutritional Status; Graves Disease; Hyperthyroidism; Thyrotoxicosis
PubMed: 37900151
DOI: 10.3389/fendo.2023.1234918 -
Endocrine Connections May 2022Evidence on the efficacy and safety of anticoagulation in preventing stroke and thromboembolic events in people with thyrotoxic atrial fibrillation is scarce.
BACKGROUND
Evidence on the efficacy and safety of anticoagulation in preventing stroke and thromboembolic events in people with thyrotoxic atrial fibrillation is scarce.
OBJECTIVE
We evaluated the efficacy and safety of anticoagulation in people with thyrotoxic atrial fibrillation.
METHODS
Our study protocol was published in the International Prospective Register of Systematic Reviews (registration no. CRD42020222782). Four databases and two systematic review registers were searched through 25 November 2020 for interventional and observational studies comparing anticoagulation therapy with active comparators, placebo, or no treatment in people with thyrotoxic atrial fibrillation. Random-effects meta-analysis and sensitivity analysis were performed. Quality of evidence was described using the GRADE framework.
RESULTS
In the study, 23,145 records were retrieved. One randomized controlled trial and eight cohort studies were ultimately included. Effect estimates on the efficacy and safety of anticoagulation were extracted. Meta-analysis using the inverse variance and random-effects methods was conducted on four cohort studies with 3443 participants and 277 events. Anticoagulation in people with thyrotoxic atrial fibrillation reduced the risk of ischemic stroke and systemic thromboembolism by 3% (95% CI: 1-6%). Warfarin may prevent ischemic stroke in people with thyrotoxic atrial fibrillation if the CHA2DS2-VASc score exceeds 1 and when atrial fibrillation persists beyond 7 days. Direct oral anticoagulants may be associated with fewer bleeding events than warfarin.
CONCLUSIONS
Anticoagulation prevents ischemic stroke and systemic thromboembolism in people with thyrotoxic atrial fibrillation. Direct oral anticoagulants may be associated with fewer bleeding events.
PubMed: 35521808
DOI: 10.1530/EC-22-0166 -
Diagnostics (Basel, Switzerland) Sep 2023Thyroid storm (TS) is a rare and fatal endocrine emergency that occurs due to undiagnosed and inadequately treated hyperthyroidism after stressful conditions in patients... (Review)
Review
Thyroid storm (TS) is a rare and fatal endocrine emergency that occurs due to undiagnosed and inadequately treated hyperthyroidism after stressful conditions in patients with thyroid disorders. The objective of this systematic scoping review was to better understand the pathophysiology of TS and its complications, in terms of myocardial affection, tachyarrhythmia, and cardiogenic shock. In addition, we explored the pharmacological, mechanical, and surgical treatments for TS. We also evaluated the outcomes of TS according to sex and cardiac involvement. Additionally, analytical analysis was performed on the selected data. A literature review of peer-reviewed journals was carried out thoroughly using medical terms, MeSH on PubMed, Google Scholar, and combinations such as thyrotoxicosis-induced cardiomyopathy, thyroid storm, cardiogenic shock, myocardial infarction, endocrine emergency, Burch-Wartofsky score, extracorporeal circulatory support, and thyroidectomy. A total of 231 papers were eligible (2 retrospective studies, 5 case series, and 224 case reports) with a total of 256 TS patients with cardiac involvement between April 2003 and August 2023. All age groups, sexes, patients with TS-induced cardiomyopathy, non-atherosclerotic myocardial infarction, tachyarrhythmia, heart failure, shock, and different forms of treatment were discussed. Non-English language articles, cases without cardiac involvement, and cases in which treatment modalities were not specified were excluded. Female sex was predominant, with 154 female and 102 male patients. Approximately 82% of patients received beta-blockers (BBs), 16.3% were placed on extracorporeal membrane oxygenation (ECMO) support, 16.3% received therapeutic plasma exchange (TPE), and 13.8% underwent continuous renal replacement therapy (CRRT), continuous venovenous hemofiltration (CVVHD), or dialysis. Overall, 18 females and 16 males died. BB-induced circulatory collapse, acute renal failure, CRRT, and ventricular fibrillation were significantly associated with mortality. Awareness of TS and not only thyrotoxicosis is vital for timely and appropriate treatment. The early diagnosis and management of TS in cardiac settings, including pharmacological, mechanical, and surgical modalities, can save high-risk patients. Sex matters in the presentation, treatment, and mortality of this population. However, further large-scale, and well-designed studies are required.
PubMed: 37835772
DOI: 10.3390/diagnostics13193028 -
Internal Medicine Journal Apr 2022COVID-19 is known to cause an acute respiratory illness, although clinical manifestations outside of the respiratory tract may occur. Early reports have identified... (Review)
Review
BACKGROUND
COVID-19 is known to cause an acute respiratory illness, although clinical manifestations outside of the respiratory tract may occur. Early reports have identified SARS-CoV-2 as a cause of subacute thyroiditis (SAT).
METHODS
A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, Web of Science and PubMed databases were queried in February 2021 for studies from December 2019 to February 2021. MeSH search terms 'COVID-19', 'SARS-CoV-2' and 'coronavirus' along with search terms 'thyroiditis', 'thyrotoxicosis' and 'thyroid' were used. Descriptive statistics for continuous variables and proportions for categorical variables were calculated.
RESULTS
Fifteen publications reporting on 17 individual cases of COVID-19-induced SAT were identified. Age ranged from 18 to 69 years. The majority (14 of 17; 82%) of cases were female. The delay between onset of respiratory symptoms and diagnosis of SAT ranged from 5 to 49 days (mean, 26.5). Systemic inflammatory response syndrome related to viral infection was uncommonly reported at the time of SAT diagnosis. Thyroid ultrasonography frequently reported an enlarged hypoechoic thyroid with decreased vascularity and heterogenous echotexture. Elevated C-reactive protein (CRP) was common at the time of SAT diagnosis, with results ranging from 4.5 to 176 mg/L (mean, 41 mg/L). Antithyroid antibodies were frequently negative. SAT-specific treatment included corticosteroids for 12 of 17 (70.5%) patients. Most returned to normal thyroid status.
CONCLUSION
COVID-19-associated SAT may be difficult to identify in a timely manner due to potential absence of classic symptoms, as well as cross-over of common clinical features between COVID-19 and thyrotoxicosis.
Topics: Adolescent; Adult; Aged; COVID-19; Female; Humans; Male; Middle Aged; Risk Factors; SARS-CoV-2; Thyroiditis, Subacute; Thyrotoxicosis; Treatment Outcome; Young Adult
PubMed: 34139048
DOI: 10.1111/imj.15432 -
International Journal of Surgery... Feb 2017Use of intra-operative neuro-monitoring (IONM) during high-risk thyroidectomy has been suggested to decrease the rate of recurrent laryngeal nerve (RLN) palsy. However,... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Use of intra-operative neuro-monitoring (IONM) during high-risk thyroidectomy has been suggested to decrease the rate of recurrent laryngeal nerve (RLN) palsy. However, current evidences were mixed and there was no large-scale study concluding its benefit. We evaluated the role of IONM in reducing RLN palsy during high-risk thyroidectomy and identified which high-risk subgroup would be most benefited.
METHODS
A systemic review was performed to identify studies comparing the use of IONM and visual identification of RLN alone (VA) during high-risk thyroidectomy, namely re-operation, thyroidectomy for malignancy, thyrotoxicosis or retrosternal goitre. Rate of RLN palsy was presented in terms of number of nerve-at-risk (NAR). Meta-analysis on overall high-risk thyroidectomy and subgroups were performed using fixed or random-effects model.
RESULTS
Ten articles were eligible for final analysis. There were 4460 NARs in VA group and 6155 NARs in IONM group. Comparing to VA, IONM had lower rate of overall [4.5% vs. 2.5%, Odd ratio (OR): 1.40, 95% confidence interval (CI): 1.12-1.79, p = 0.003] and temporary [3.9% vs. 2.4%; OR: 1.47, 95% CI: 1.07-2.00, p = 0.016] RLN palsy in overall high-risk thyroidectomies. On subgroup analysis, although numbers of NARs were less than minimal numbers required for a statistical powered study (2.1%-72.7%), use of IONM decreased the rate of overall RLN palsy during re-operation (7.6% vs. 4.5%, OR: 1.32, p = 0.021) and temporary RLN palsy during thyroidectomy for malignancy (3.1% vs. 1.6%, OR: 1.90, p = 0.026). Use of IONM tended to have a lower rate of overall RLN palsy during thyroidectomy for malignancy than VA alone. (3.5% vs. 2.1%, p = 0.050).
CONCLUSIONS
Selective use of IONM during high-risk thyroidectomy decreased the rate of overall RLN palsy. IONM should be applied during re-operative thyroidectomy and thyroidectomy for malignancy.
Topics: Female; Humans; Intraoperative Neurophysiological Monitoring; Male; Middle Aged; Recurrent Laryngeal Nerve Injuries; Reoperation; Risk; Thyroidectomy; Vocal Cord Paralysis
PubMed: 28034775
DOI: 10.1016/j.ijsu.2016.12.039 -
Molecular and Clinical Oncology Dec 2019Hyperthyroidism may be caused by the development of primary or metastatic thyroid carcinoma. The aim of the present study was to collect recently reported cases of...
Hyperthyroidism may be caused by the development of primary or metastatic thyroid carcinoma. The aim of the present study was to collect recently reported cases of hyperfunctioning thyroid carcinoma in order to analyze its pathological characteristics, diagnostic procedures and treatment strategies. A PubMed (https://www.ncbi.nlm.nih.gov/pubmed/) search was performed for studies published between January 1990 and July 2017. Full-text articles were identified using the terms, 'hyperfunctioning thyroid carcinoma/cancer', 'malignant hot/toxic thyroid nodule', or 'hyperfunctioning papillary/follicular/Hürthle thyroid carcinoma'. Original research papers, case reports and review articles were included. Among all thyroid carcinoma cases included in the present study, the prevalence of follicular thyroid carcinoma (FTC) was ~10%; however, the prevalence of FTC among hyperfunctioning thyroid carcinomas was markedly higher (46.5% in primary and 71.4% in metastatic disease). The size of hyperfunctioning thyroid tumors was considerably larger compared with that of non-hyperfunctioning thyroid tumors, with a mean size of 4.25±2.12 cm in primary hyperfunctioning thyroid carcinomas. In addition, in cases of metastatic hyperfunctioning thyroid carcinoma, tumor metastases were widespread or large in size. The diagnosis of primary hyperfunctioning thyroid carcinoma is based on the following criteria: i) No improvement in thyrotoxicosis following radioactive iodine (RAI) treatment; ii) development of hypoechoic solid nodules with microcalcifications on ultrasound examination; iii) increase in tumor size over a short time period; iv) fixation of the tumor to adjacent structures; and v) signs/symptoms of tumor invasion. The diagnosis of metastatic hyperfunctioning thyroid carcinoma should be considered in patients suffering from thyrotoxicosis who present with a high number of metastatic lesions (as determined by whole-body scanning), or a history of total thyroidectomy. Surgery is the first-line treatment option for patients with primary hyperfunctioning thyroid carcinoma, as it does not only confirm the diagnosis following pathological examination, but also resolves thyrotoxicosis and is a curative cancer treatment. RAI is a suitable treatment option for patients with hyperfunctioning thyroid carcinoma who present with metastatic lesions.
PubMed: 31798874
DOI: 10.3892/mco.2019.1927 -
Current Cardiology Reviews 2020A grave complication of thyrotoxicosis, or thyroid storm, is the development of heart failure and cardiomyopathy. Recognizing this condition is imperative in preventing...
BACKGROUND
A grave complication of thyrotoxicosis, or thyroid storm, is the development of heart failure and cardiomyopathy. Recognizing this condition is imperative in preventing further left ventricular dysfunction and cardiogenic shock. This manuscript aims to review the literature on cardiogenic shock associated with thyrotoxicosis and present management recommendations on this rare condition.
METHODS
A literature search was performed in December of 2018, using the PubMed medical search engine. A systematic search was carried out using the keywords Thyroid Storm AND Cardiogenic Shock and Thyrotoxicosis AND Shock.
MANAGEMENT
Decrease of thyroid hormone levels using therapeutic plasma exchange LV Unloading and ventilation by Impella and Extracorporeal Mechanical Ventilation (ECMO).
CONCLUSION
Patients presenting with thyroid storm-induced shock may not be suitable candidates for traditional management with β -adrenergic blockers (β-blockers). The use of β-blockers could exasperate their condition. Through extensive literature review on this rare condition, the most effective management was found to be therapeutic plasma exchange in order to decrease thyroid hormone levels, which have direct toxic effect on the heart. Furthermore, the use of ECMO and Impella is advised to reduce pressure on the heart and ensure the patient's organs are well oxygenated and perfused while the left ventricle is recovering.
Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Shock, Cardiogenic; Survival Analysis; Thyrotoxicosis
PubMed: 32167428
DOI: 10.2174/1573403X16666200313103657