Impact of thyroid function screening in a large cohort of patients admitted to an emergency department.

BACKGROUND: Thyroid dysfunctions are highly prevalent and can worsen underlying cardiopathies, but despite that the routine screening of thyroid function in the Emergency Department (ED) setting is not generally recommended. OBJECTIVE: To understand if staff training and implementation of rapid TSH screening (rTSH) could improve the management of patients arrived in the ED. Specifically, we aimed at evaluating the prevalence of undiagnosed thyroid diseases among ED patients; the effects of educational meetings in the clinical decision-making process; the usefulness of rTSH, in terms of variation of either the clinical work out or the existing treatment. DESIGN: Retrospective case-control study of 9227 patients managed in the ED of an academic institution. rTSH was routinely available for all patients, who were divided into rTSH-YES and rTSH-NO groups. RESULTS: We included 4243 and 4984  patients in the rTSH-YES and rTSH-NO group, respectively. Trained personnel uncovered a high prevalence of undiagnosed thyroid dysfunction (7%). The diagnosis in the ED of heart failure, history of thyroid diseases, contrast media/amiodarone administration and female gender were independently associated with an increased likelihood to have thyroid dysfunction. The rTSH improved the clinical outcome by (a) appropriate treatment of an underlying clinical condition causing ED entrance, (b) appropriate prophylaxis in patients requiring contrast media, (c) uncovering incorrect treatments, with 60% of patients on levothyroxine requiring a dose reduction. CONCLUSIONS: The rTSH in the ED revealed a high prevalence of untreated thyroid disorders with a major impact on following interventions. The training of a multidisciplinary team is crucial in driving the correct decision-making process.

Pulsed intravenous methylprednisolone combined with oral steroids as a treatment for poorly responsive type 2 amiodarone-induced thyrotoxicosis.

OBJECTIVES: Amiodarone-induced thyrotoxicosis (AIT) affects up to 3% of treated patients. Type 2 AIT (AIT2) is a destructive thyroiditis and is usually treated with medium-high oral doses of prednisone. As AIT may worsen the underlying heart disease, a rapid control of thyroid function is desirable. We aimed to determine whether a combined intravenous methylprednisolone (IVMP) pulses therapy associated to prednisone in the interpulse period can represent an efficient and safe alternative to urgent total thyroidectomy in patients with AIT2 not responsive to prednisone alone. DESIGN AND METHODS: Patients presenting with a severe AIT2 studied in a tertiary referral Center from August 2018 to April 2019. We included four patients requiring a rapid improvement of thyroid function for their underlying cardiac disorders. The baseline doses of oral prednisone (range: 5-12.5 mg/day) and IVMP (range: 250-500 twice a week) were determined according to the severity of the thyrotoxicosis and were titrated based on clinical response. RESULTS: Combined treatment was effective in all patients in the prompt restoration of euthyroidism and no major adverse events were reported during the follow-up. In all cases, FT4 and FT3 levels normalized at 3-5 weeks of treatment. A permanent hypothyroidism was observed in one patient, 3 months after the discontinuation of treatment. CONCLUSIONS: We report for the first time that the combined intravenous and oral steroid therapy is effective in patients with AIT2. The treatment is well tolerated and leads to a rapid improvement of thyroid function, avoiding urgent total thyroidectomy and favoring a quick functional recovery and rehabilitation of cardiac patients.