Thyroid storm, although rare, occurs in approximately one of six hospitalized patients with a major diagnosis of thyrotoxicosis, but the disease is associated with a 12-fold higher mortality rate than thyrotoxicosis without a thyroid storm, according to new research.

"Emergency care providers, emergency rooms and / or hospitals should be aware of the high morbidity and mortality of the thyroid storm", first author, Rodolfo J. Galindo, MD, Assistant Professor of Medicine and Clinical Researcher at the Division. of Endocrinology at the Emory University School of Medicine in Atlanta, Georgia, said Medscape Medical News.

"Collaborative efforts are needed to develop standardized, evidence-based strategies – not just recommendations from expert opinions – to diagnose and treat these patients," he said. .

Thyroid storm, a severe form of thyrotoxicosis, is a life-threatening thyrotoxic crisis; However, the understanding of the rare disease, including incidence and mortality rates, is mainly based on a series of monocentric cases that are not very recent.

the new study, published online in Thyroid, is the first nationwide analysis of hospitalized patients with thyroid storm in the United States. Galindo and his colleagues conducted a longitudinal analysis using National Inpatient Sample (NIS) data.

Galindo thinks that a patient registry is now needed to properly track thyroid storm cases nationwide and inform future treatment recommendations. Meanwhile, doctors can use Burch-Wartofsky's point scale to distinguish a simple thyrotoxicosis from the "imminent" or well-established thyroid storm, he says.

In addition, "Clinicians, including Emergency Medicine Specialists, Hospitals and / or Internists, should be properly trained in the use of supportive care and thionamide-based medications in the community. patients with hyperthyroidismand advised to consult endocrinology specialists in a timely manner, as delay in treatment can lead to increased morbidity and mortality, "he urged.

About 15% of cases of severe hyperthyroidism have a thyroid storm

The thyroid storm is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones in people with thyrotoxicosis. The thyroid may be the initial manifestation of thyrotoxicosis in undiagnosed children, particularly in newborns, although this condition is rare in children.

Since the thyroid storm is almost always fatal if left untreated, rapid diagnosis and aggressive treatment are essential. The diagnosis is mainly clinical and no specific laboratory test is available.

In the new study, of the 121,384 hospital discharges with thyrotoxicosis identified between 2004 and 2013, 19,723 (16.2%) were diagnosed with a thyroid storm, with overall incidence rates ranging from 0.57 and 0.76 cases per 100,000 population in the United States and between and 5.6 per 100,000 hospitalized patients per year.

Hospital mortality rates were significantly higher in patients with thyroid storm than in those with thyrotoxicosis but without a thyroid storm (1.2-3.6% vs. 0.1-0.4%; P <0.01) and the mean length of stay was also longer with a thyroid storm (4.8 to 5.6 days vs. 2.7 to 3.4 mean days; P <0.001).

The characteristics of patients with thyrotoxicosis, whether they had a thyroid storm or not, were similar, the majority being middle-aged and Caucasian and about 76% female.

There were no significant differences in mortality rates between ethnic groups; however, Hispanics and African Americans were more likely than whites to be diagnosed with thyrotoxicosis complicated by a thyroid storm (20.8% vs. 18.7% vs. 13.7%); P <.0001).

Patients with a thyroid storm were also more likely to have a history of Graves' disease (51.1% vs. 41.4%; P <0.001) and a history of drug non-compliance (15.4% vs. 5.9%; P <0.001)

After multivariate adjustment, a younger age and a Charlson score of less than 3 were associated with a lower mortality risk with a thyroid storm (P <0.05).

Costs, but not cases, increase

Although the incidence of thyroid storms does not appear to increase, the costs associated with the disease have been steadily increasing since 2007, with average admission-related hospitalization costs adjusted for inflation from $ 9942 to $ 12,661 at patients with thyrotoxicosis with thyroid storm from 2004 to 2013 (P <0.001).

"From a policy perspective, these results are noteworthy, as trends in incidence, mortality, and length of stay of the thyroid storm were stable over the period of time. study, write the authors.

Factors that could have contributed to higher costs could include those associated with cardiovascular comorbidities of the thyroid storm, they speculate.

In the study, people with a thyroid storm had higher rates of cardiovascular disease, including ventricular arrhythmia (2.5% vs. 1.2%; P <0.001), episodes of cardiac arrest (1.3% vs 0.1%; P <0.001) cardiac arrest (19.4% vs. 10.3%; P <0.001), and acute coronary syndromes (1.8% vs. 0.7%; P <0.001).

Thyroid patients also had higher rates of acute respiratory failure during hospitalization (5.9% vs. 0.8%; P<0.001) compared to those without a thyroid storm.

"It is suspected that the higher rate of severe and acute cardiopulmonary pathologies and the need for more invasive cardiac procedures and mechanical ventilation, which usually require admissions to coronary or intensive care units, may have had an impact on increased costs, "explain the authors.

Call for action for the registry of patients undergoing a thyroid storm

Galindo noted that hospital mortality rates of up to 3.6% for the thyroid storm are below the 8% to 10% reported in previous reports; However, the differences may reflect different treatment parameters.

"This study combines data from university and non-university, urban and rural hospitals in the United States, while previous reports were limited to postgraduate university centers, where both acuity and mortality could be higher, "he said.

Nevertheless, with such high morbidity and mortality rates, better documentation of the thyroid storm is needed – beyond what can be proposed in the NIS database, Galindo said.

"The database used [NIS] can provide us with valuable information to understand the clinical burden and impact of this disease on the health care system in the United States. However, it has not been developed as a research tool, "he explained.

"So, we [propose] a call to action for the creation of a prospective patient registry, including clinical, laboratory and treatment data, to inform future evidence-based management recommendations for this condition . "

Until then, Galindo reiterated that clinicians could use Burch-Wartofsky's point scale to differentiate uncomplicated thyrotoxicosis from the thyroid storm.

Galindo has not reported any relevant financial relationship.

Thyroid.Posted online December 18, 2018. Abstract

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