Thiocyanate in excess develops goiter followed by auto immune thyroid diseases even after effective salt iodization in a rural community of north east India.

PURPOSE: Salt iodization in Manipur of north-east India failed to prevent endemic goiter, therefore an in depth study carried out to evaluate thyroid functions of goitrous subjects in a randomly selected region. METHODS: Goiter survey conducted in children and women of reproductive ages by palpation followed by measurement of urinary iodine, thiocyanate and house-hold salt iodine to evaluate iodine nutritional status and consumption pattern of bamboo-shoots (BS). In all grade-2 goitrous subjects, free thyroxine, triiodothyronine, TSH, TPO and Tg antibodies, thyroid volume and echogenecity by ultrasonography and cytomorphology of thyroid by FNAC studied. RESULTS: Study population was 2486 children and 1506 women, goiter prevalence was 12.59% and 16.27% respectively; median urinary iodine and mean thiocyanate were 166 µg/l and 0.729 ± 0.408 mg/dl while salt iodine was ≥30 ppm. Serum thyroid hormones and TSH profiles of all grade-2 goitrous subjects showed 16.21% were subclinically hypothyroid, 2.16% overt hypothyroid, 4.86% subclinically hyperthyroid and 6.48% overt hyperthyroid, serum TPO- and Tg-antibodies found positive in 41.62%. Ultrasonographic results showed 24% had enlarged thyroid and 86.4% hypoechoic. Cytomorphological studies showed prevalence of colloid goiter (41.08%), lymphocytic thyroiditis (37.83%), Hashimoto's thyroiditis (8.10%), autoimmune thyroiditis (4.32%), sub-acute thyroiditis (2.16%) and 1.62% each papillary, medullary carcinoma, simple diffused hyperplasia and adenomoid nodular goiter. CONCLUSIONS: Grade-2 goitrous individuals in this mild goiter endemic region were affected by hypo- and hyperthyroidism with hypoechoic thyroid and thyroiditis. Thiocyanate that originates from BS even in presence of adequate iodine developed goiter and led goitrous population towards such diseases.

State of the art: surgery for endemic goiter--a plea for individualizing the extent of resection instead of heading for routine total thyroidectomy.

BACKGROUND: During the past 150 years of nodular goiter surgery, the pendulum has been swinging from limited to more extensive forms of thyroidectomy and all the way back reflecting the challenges of striking a balance between surgical morbidity and disease recurrence. PURPOSE: This article aimed at providing guidance for individualizing decisions using a risk-oriented surgical approach to endemic goiter based on literature review and personal experience. DISCUSSION: The following arguments favor total thyroidectomy: (a) Endemic goiter involves the entire thyroid gland; (b) Increasing standardization and specialization supported by better visualization, surgical devices, and intraoperative parathyroid hormone assays have decreased surgical morbidity; (c) One third of goiter patients require completion thyroidectomy for incidental thyroid cancer; (d) Recurrent goiter is frequently seen on ultrasonography after subtotal thyroidectomy; (e) Thyroid hormone replacement is well tolerated and inexpensive. Important counter-arguments include: (a) Restoration of iodine sufficiency does not reverse nodular goiter nor can the growth of individual nodules be predicted; (b) To gather the annual case load necessary to achieve improved outcomes, surgeons need to "super-specialize", which may not be viable globally; (c) Many incidental cancers are detectable through high-resolution ultrasonography, fine needle aspiration cytology, and frozen section during thyroidectomy; (d) Not all recurrent goiters require reoperations; (e) Thyroid hormone replacement is not available and affordable everywhere. CONCLUSION: The higher surgical morbidity associated with total thyroidectomy, notably recurrent laryngeal nerve palsy and hypoparathyroidism, calls for individualizing the extent of resection for endemic goiter as a new standard of care instead of heading for routine total thyroidectomy.

Malignancy rates in operated patients with hyperthyroidism in an area of endemic goiter.

We aimed to evaluate the incidence of thyroid cancer in Turkish patients with hyperthyroidism who had undergone thyroid surgery. The data of 344 patients who had been operated on for hyperthyroidism between 1998 and 2006 at our center were evaluated retrospectively. Sixty-five of the subjects had single toxic adenomas, 223 had toxic multinodular goiter, and 56 had Graves' disease. In 35 of 344 patients (10.1%), papillary carcinoma was diagnosed. Other forms of thyroid carcinomas were not observed. The rate of carcinoma was found to be 11.6% in patients with toxic multinodular goiter, 7.7% in patients with single toxic adenomas, and 7.1% in patients with Graves' disease. Occult papillary carcinoma was found in 62.9% of all malignancy diagnoses. The primary aim in the surgical treatment of hyperthyroidism should be to abolish the hyperthyroid state. However, the probability of malignancy, especially occult carcinoma, should always be considered.

Iodine Deficiency and Toxicity Among School Children in Damoh District, Madhya Pradesh, India.

OBJECTIVE: To estimate the prevalence of Iodine Deficiency Disorders, and household consumption of adequately iodized salt in Damoh district, Madhya Pradesh in 2016. METHODS: Cross-sectional study with cluster sampling method was used among school-going children. 30 clusters, each with 90 children were selected to access Total Goiter rate (TGR). 540 salt samples were collected to estimate salt iodine content from their household and 270 on the spot urine samples were collected to estimate Urine Iodine Excretion level. RESULTS: TGR was 2.08%. The prevalence of iodine deficiency, adequate iodine nutrition, and either more than adequate or toxic level of Iodine was 26%, 28% and 46 %, respectively. 72.4% people were consuming adequately iodized salt. CONCLUSION: Damoh district is no more an endemic area for iodine deficiency. We recommend continuous monitoring to assess IDDs as well Iodine-induced toxicity in future.

Evaluation of endemic goiter prevalence in Bulgarian schoolchildren: results from national strategies for prevention and control of iodine-deficiency disorders.

Iodine deficiency is a major health problem worldwide. The environment of the Balkan countries, including Bulgaria, is distinguished for its low iodine content. In 1994, the strategies for the prevention and control of iodinedeficiency disorders were actualized in Bulgaria and universal salt iodization and supplementation for the risk population groups (schoolchildren, pregnant women) were introduced. The aim of this study was to assess the effectiveness of the iodine prophylaxis in schoolchildren, living in an endemic for goiter area after the introduction of salt iodization in Bulgaria. For this purpose, the goiter prevalence and iodine status in 483 schoolchildren (274 boys and 209 girls) aged between 8 and 15 yr, living in an endemic for goiter area in Bulgaria were evaluated. Despite the normalization of iodine supply, mild iodine deficiency on the basis of goiter prevalence (16.15%) and urinary iodine excretion was found. These data indicate the need for reevaluation of the national strategy for prevention of iodine deficiency.

[Iodine nutritional status in the school-aged population in Alicante (Spain)]. / Situación nutricional de yodo en la población escolar de Alicante.

BACKGROUND: According to the World Health Organization (WHO), goiter is endemic in Spain. The main cause of endemic goiter is iodine deficiency, which is also the principal cause of mental retardation and avoidable cerebral palsy throughout the world. MATERIAL AND METHODS: We conducted an observational study to determine the prevalence of endemic goiter and nutritional iodine status in the province of Alicante. Urinary iodine excretion was measured in a morning urine sample, and thyroid volume was measured by means of a thyroid ultrasound scan. A case of goiter was diagnosed if thyroid volume was above the 97th percentile adjusted by age, as published by the WHO. RESULTS: No cases of goiter were found. In addition, the median urinary iodine excretion levels adjusted by age were within the normal range, as defined by the WHO's criteria. CONCLUSIONS: Endemic goiter was not found in the province of Alicante and urinary iodine excretion values demonstrated adequate iodine intake. Further ultrasound studies are needed to establish reference thyroid volumes for our population.

[Endemic goiter and iodine deficiency: are they still a reality in Spain]. / Bocio endémico y déficit de yodo: 'sigue siendo una realidad en España?

OBJECTIVE: To estimate the prevalence of goiter and iodine deficiency in a health district in the Autonomous Community of Valencia, given the absence of data in this region of Spain. MATERIAL AND METHODS: We conducted a descriptive, epidemiologic, cross-sectional study, stratified by age and sex, in four interior regions of the province of Valencia. We selected students aged from 6 to 14 years old in 20 centers. Thyroid examination was performed by means of palpation and inspection (goiter > or = 0B). Urinary iodine excretion was analyzed in a routine urine sample. Sociodemographic and anthropometric data, as well as nutritional iodine status, were recorded in a standardized survey. In children with goiter, thyroid-stimulating hormone (TSH), free T4, and antithyroid antibodies were determined. RESULTS: We studied 928 children (478 boys and 450 girls). The prevalence of goiter was 33.7 % (95 % CI: 30.7-36.9 %). There were no significant differences in the prevalence of goiter by age or sex, but an inverse correlation was detected between the prevalence of goiter and parental socioeconomic position. Mean urinary iodine excretion was 155 .g/l, with no significant correlation with the prevalence of goiter. In children with goiter, 13 had positive antithyroid antibodies, 18 had high TSH (subclinical hypothyroidism), and one had suppressed TSH (subclinical hyperthyroidism). CONCLUSIONS: There is endemic goiter in the region studied. Urinary iodine levels were in the normal range and could be interpreted as indicating a transition phase to an improvement in iodine deficiency. Autoimmune diseases would only explain 4 % of cases of goiter.

Thyroid Disorders in Children and Adolescents: A Review.

IMPORTANCE: Normal thyroid gland function is critical for early neurocognitive development, as well as for growth and development throughout childhood and adolescence. Thyroid disorders are common, and attention to physical examination findings, combined with selected laboratory and radiologic tools, aids in the early diagnosis and treatment. OBJECTIVE: To provide a practical review of the presentation, evaluation, and treatment of thyroid disorders commonly encountered in a primary care practice. EVIDENCE REVIEW: We performed a literature review using the PubMed database. Results focused on reviews and articles published from January 1, 2010, through December 31, 2015. Articles published earlier than 2010 were included when appropriate for historical perspective. Our review emphasized evidence-based management practices for the clinician, as well as consensus statements and guidelines. A total of 479 articles for critical review were selected based on their relevance to the incidence, pathophysiology, laboratory evaluation, radiological assessment, and treatment of hypothyroidism, hyperthyroidism, thyroid nodules, and thyroid cancer in children and adolescents. Eighty-three publications were selected for inclusion in this article based on their relevance to these topics. FINDINGS: The primary care physician is often the first health care professional responsible for initiating the evaluation of a thyroid disorder in children and adolescents. Patients may be referred secondary to an abnormal newborn screening, self-referred after a caregiver raises concern, or identified to be at risk of a thyroid disorder based on findings from a routine well-child visit. Irrespective of the path of referral, knowledge of the signs and symptoms of hypothyroidism, hyperthyroidism, and thyroid nodules, as well as the general approach to evaluation and management, will help the primary care physician complete an initial assessment and determine which patients would benefit from referral to a pediatric endocrinologist. CONCLUSIONS AND RELEVANCE: Early identification and treatment of thyroid disease in children and adolescents is critical to optimize growth and development. The primary care physician plays a critical role in identifying patients at risk. An understanding of risk factors, clinical signs and symptoms, and interpretation of screening laboratories ensures an efficient and accurate diagnosis of these common disorders. Regular communication between the primary care physician and the subspecialist is critical to optimize outcome because the majority of patients with thyroid disorders will require long-term to lifelong medical therapy and/or surveillance.

Surgery is the procedure of choice for the treatment of patients with toxic adenoma in an endemic goitre area.

PURPOSE: Toxic adenoma is one of the main causes of hyperthyroidism. We investigated the efficacy of surgery in the treatment of toxic adenoma. METHODS: Serum thyroid stimulating hormone (TSH) measurement, ultrasound and scintigraphy of the thyroid were made for diagnostic purpose. The safety of surgery was evaluated by postoperative clinical course of patients. The efficacy of surgery was determined by the function of the remaining thyroid tissue. RESULTS: The incidence of hyperthyroidism was 53% in surgically treated patients with nodular goitre in our iodine deficient region. The cause of thyrotoxicosis was toxic adenoma in 15 patients (14%). Suppressed serum TSH levels indicated the hyperthyroidism in all of 15 patients. Solitary solid adenoma was found by ultrasonographic examination, and solitary autonomous hot nodule by thyroid scintigraphy. Surgical treatment consisted of unilateral total lobectomy. It was the primary treatment in 13 patients. Two patients had surgery as secondary treatment after unsuccessful primary radioactive iodine application. The early postoperative clinical course of all patients was uneventful. Thirteen patients who had surgery as primary treatment had normal thyroid function postoperatively contrary to other two patients who became hypothyroid after having unsuccessful radioiodine therapy, and surgery as the secondary treatment. CONCLUSIONS: The incidence of hyperthyroidism and toxic adenoma is high in our surgically treated patients with nodular goitre. The diagnosis of toxic adenoma is not difficult by serum TSH measurements, and ultrasound and nuclear imaging of the thyroid. Surgery is effective and safe, and the treatment of choice for patients with toxic adenoma in order to control radically the hyperthyroidism and to achieve the goal of providing the euthyroid status.

Clinical importance of solitary solid nodule of the thyroid in endemic goiter region.

CONTEXT: Endemic area and iodine supplementation may affect the pathogenesis of the nodule which commonly occurs in endemic thyroid enlargement due to iodine deficiency. AIMS: To establish pathological changes in solitary solid and larger nodule of the thyroid in endemic area. SETTING AND DESIGN: Retrospective study in Surgical Department of University Hospital. METHODS AND MATERIAL: We determined 44 surgically treated patients with solitary solid nodule in endemic goiter area in which the population routinely receives iodinated salt. The thyroid nodule was preoperatively evaluated with blood chemistry, ultrasound, nuclear scanning and FNAC. The results of preoperative evaluation, surgical interventions, and histopathological examination were analyzed. STATISTICAL ANALYSIS: Student t test and Fisher's exact test. RESULTS: Twenty (45%;20/44) patients with hot (autonomous) nodule have received the diagnosis of toxic adenoma. Twenty four patients had solitary solid and cold nodule. Total thyroidectomy was performed on two patients with papillary cancer (PTC) diagnosed by FNAC from cold nodules. Forty two patients have been treated with total excision of the lobe including hyper or hypoactive solitary solid nodule. Pathological examination has reported two more cases of PTC and one case of insular cancer arising from cold nodules. Completion thyroidectomy was performed on these 3 patients. CONCLUSIONS: Solitary solid and large nodule is a common indication for thyroid surgery in endemic goiter area. High incidence of hyperthyroidism due to single autonomous nodule, and high rate of malignant change (mainly papillary cancer) in solitary hypoactive nodule arises from this series in endemic thyroid enlargement.

[Thyroid surgery applicable in developing countries]. / Chirurgie de la thyroïde applicable dans les pays en développement.

Thyroid surgery in developing countries is performed by general surgeons with limited diagnostic and therapeutic resources. The aim of this review is to describe the indications for and appropriate type of surgery according to the diseases observed. Endemic goiter (grade 1 and 2) usually regresses with iodine therapy. Surgery is indicated only for its complications: mechanical, neoplastic, or related to hyperthyroidism. The choice of operation depends on the specific disease and also on the likelihood that thyroxine will be continuously available for the patient's lifetime. Total thyroidectomy should be avoided whenever possible if thyroxine supplies are unreliable. Hemithyroidectomy and subtotal thyroidectomy are the techniques that should be used in priority.

Effect of maternal iodine supplementation on thyroid function and birth outcome in goiter endemic areas.

OBJECTIVE: The study was undertaken to examine the clinical and endocrine parameters of thyroid in a total of 460 pregnant women belonging to non-goiter areas (group 1; n = 156) and endemic areas without (group 2; n = 154) and with iodine supplementation (group 3; n = 150), and their respective newborns. METHODS: Women of group 3 with visible goiter were administered two capsules of iodized oil orally each containing 200 mg of iodine, from weeks 6--8 of pregnancy. Blood samples were obtained from all groups during each trimester, at parturition (umbilical cord blood) and after delivery. Serum triiodothyronine (T3), thyroxine (T4) and thyroid stimulating hormone (TSH) levels were measured by specific enzyme immunoassays. RESULTS: In group 2, serum T4 concentrations were low while T3 and TSH levels were high which showed hypothyroidism in the women of endemic areas. Goiter size decreased in most of the subjects who received a single dose of iodized oil and resulted in increase in serum concentrations of thyroid hormones; whereas, TSH levels decreased. Iodine supplementation also resulted in raised T4 and low TSH levels in the cord blood of neonates. During the course of study, two abortions, three still births and one cretin were reported in group 2; none was reported in group 3; and one still birth was reported in group 1. CONCLUSIONS: The oral administration of a single dose of iodized oil is capable of correcting iodine deficiency both clinically and endocrinologically in mothers and neonates. Iodine supplementation has the potential to positively impact the birth weight of newborns.

Maternal Overt Hypothyroidism and Neurobehavioral Outcome of Neonates: A Cohort Study from an Iodine-deficient Area of Northern India.

OBJECTIVE: To study the relation between maternal overt hypothyroidism and neurodevelopmental outcome of neonates in iodine-deficient region of Northern India (Kashmir Valley). DESIGN: Prospective cohort study. SETTING: Endocrinology department of a tertiary-care hospital. PARTICIPANTS: 82 hypothyroid pregnant women were enrolled and followed up till delivery. The neonates born to this group represented the case neonates. 51 euthyroid healthy pregnant women were selected as control group. The neonates born to these mothers served as controls. MAIN OUTCOME MEASURES: Early neonatal behavioral assessment at 3-4 weeks of age. RESULTS: The mean TSH and free T4 in neonates of mothers with well controlled hypothyroidism was significantly different from those born to mothers with poorly controlled hypothyroidism and controls in 1st trimester, but the difference was statistically insignificant for 2nd and 3rd trimester values. CONCLUSION: Overt maternal hypothyroidism in iodine-deficient area constitutes a risk factor for an abnormal neurobehavioral development of affected child.

Seven deadly sins in confronting endemic iodine deficiency, and how to avoid them.

Iodine deficiency is a problem for almost all countries of the world. Goiter is its most obvious consequence, but others do more damage, particularly effects on the developing brain. In 1990, most countries and international agencies pledged the virtual elimination of iodine deficiency by the year 2000. The technology for the assessment and implementation is sufficient to attain this goal, but translating its potential into success requires careful planning. This article reviews seven major errors that frequently occur in iodine supplementation programs and offers suggestions for their avoidance. They are 1) unreliable assessment of iodine deficiency: the best indicators are urinary iodine concentration, thyroid size (preferably by ultrasound), blood spot thyroglobulin levels, and neonatal TSH determinations; the best group for surveys is schoolchildren; 2) poor iodine supplementation plan: iodized salt is the preferred supplement; its effective application frequently requires extensive changes in salt production and marketing, and poor handling of these changes will endanger the iodization program; other measures include iodized oil, iodized water, and iodine drops; all are occasionally useful, but the long range solution should generally be iodized salt; 3) exclusion of relevant stake-holders: the program should include not only health authorities but other arms of the government as well (education, commerce, agriculture, and standards), the salt industry, health professionals, and the iodine-deficient community itself; 4) inadequate education: an understanding of the effects of iodine deficiency and the means for its correction is essential at all levels, from government to affected population; 5) insufficient monitoring: the best instruments are urinary iodine levels, iodized salt use, and thyroid size, measured in representative groups at regular intervals with public reporting of results; 6) inattention to cost: the expense of iodization must be recognized and apportioned fairly; and 7) nonsustainability: for permanent success, an iodization program must be fair to all relevant parties and accompanied by a regular system of appropriate monitoring. Only with careful avoidance of these seven "deadly sins" can the goal of sustainable elimination of iodine deficiency be achieved.

The problem of the nodular goiter.

Nodular goiter is a worldwide problem involving millions of persons. Endemic goiter, and associated cretinism, is totally preventable by ensuring an adequate dietary iodine intake and eliminating malnutrition and dietary goitrogens. Therapy, on the other hand, is difficult in that the goiters often do not regress and the cretinoid changes are irreversible. Nonendemic goiter due to autoimmune thyroid disease, genetic defects in thyroid hormone biosynthesis, and environmental goitrogens or neoplasia is not usually preventable. The usual therapy, involving TSH suppression by administration of L-thyroxine orally, will frequently bring about regression of early, diffuse goiters but is often ineffective in bringing about regression of large, multinodular goiters. In these patients, surgical removal of the goiter may be necessary for alleviation of obstructive symptoms. Further research is needed to elucidate the factors involved in the development of these multinodular goiters and to control the autocrine and paracrine factors involved in nodule growth.

Assessment of goiter in an area of endemic iodine deficiency.

Urinary iodone (UI) excretion and sonographically measured thyroid volume were investigated in 195 subjects living in 6 separate villages in the Casamance region of southeastern Senegal, West Africa. A comparison of goiter prevalence using thyroid palpation and volume measurement and of iodine excretion expressed as micrograms per gram (microg/g) creatinine or micrograms per deciliter (microg/dl) urine was undertaken, and possible pathogenetic factors were investigated. Ultrasound measured thyroid volumes were above the recommended upper limit of the reference range for an area replete in iodine in 83.1% or females, 52.3% of males, and 80.0% of children aged 13 years or younger. Overall sensitivity and specificity for palpation compared to sonographically demonstrated thyroid enlargement was 51.7% and 91.5%, respectively. Thyroid enlargement was not associated with ethnic origin, thiocyanate ingestion, HLA DR/DQ phenotype frequency, or thyroid growth-stimulating immunoglobulin (TGI) positivity. Median UI was 32 microg/g creatinine with 65.0% having values consistent with iodine deficiency (< 50 microg/g). When results were expressed as micrograms per deciliter, the percentage having values consistent with iodine deficiency (< 5.0 microg/dl) increased to 95.7%. The findings suggest a primary role for iodine deficiency in goitrogenesis in the study population. They demonstrate that classification of the severity of the endemia in this or other study populations in areas of iodine deficiency is dependent on the methods used to determine goiter prevalence (palpation or ultrasound measured thyroid enlargement), or dietary iodine status (iodine excretion expressed as micrograms per gram creatinine or micrograms per deciliter urine).

The relationship between iron status and thyroid hormones in adolescents living in an iodine deficient area.

BACKGROUND: Iron may be only one of many nutritional factors that influence thyroid hormone metabolism in iodine-deficient areas. OBJECTIVE: To evaluate the effect of iron status on thyroid hormone profile in adolescents living in a mild iodine-deficient area in Turkey. SUBJECTS: Three hundred and thirty school-aged children with mean age 14 years were examined. METHODS: Free triiodothyronine, free tetraiodothyronine and thyrotropin levels were analyzed by chemiluminescent enzyme immunoassay. Hemoglobin and mean corpuscular volume were measured with a Hemocounter. Iron and total iron binding capacity concentration were determined by colorimetric photometric methods. Ferritin level was determined by immunoturbidimetry. RESULTS: Thyroid hormone levels of the children with anemia were not significantly different compared to children without anemia. No significant correlation was found between thyroid hormones and iron status. CONCLUSION: The thyroid hormone profile was not significantly affected in this area. This survey showed no correlation between iron status and thyroid hormone levels.

Pendred's syndrome.

Although 5% of all cases of congenital deafness are caused by Pendred's syndrome, there are few reports in the literature. Seven patients with Pendred's syndrome in three families living in the same village were detected. For that reason, the syndrome is reviewed in light of the literature. The sex distribution of the patients with Pendred's syndrome and their families was recorded. We tested for thyroxine, triiodothyronine, thyroid-stimulating hormone, triiodothyronine resin uptake, and perchlorate, and performed caloric testing. In one patient, subtotal thyroidectomy was performed. In the histopathologic study, a thyroid nodule filled with colloid was found. Chromosome studies showed no anomalies in any patient. Five of the patients were deaf-mutes. We observed that the parents were cousins in all three families. These families also had healthy children, and the existence of the syndrome in both sexes points to an autosomal recessive trait.