Management of thyroid disorders in primary care: challenges and controversies.

Thyroid diseases are common, and most can be safely and effectively managed in primary care. Two of the most common reasons for thyroid function testing are fatigue and obesity, but the vast majority of affected patients do not have hypothyroidism. There is no plausible basis for the assertion that hypothyroidism commonly occurs despite normal thyroid function tests. In primary hypothyroidism all patients, except the elderly and those with ischaemic heart disease, can safely be started on a full replacement dose of thyroxine; the aim is to restore thyroid stimulating hormone (TSH) to normal. Triiodothyronine (T3) has no role in the treatment of primary hypothyroidism. Subclinical thyroid disease should not be treated except in certain well defined situations. Its main importance lies in the increased risk of progression to overt thyroid disease. The development of hyperthyroidism is easily overlooked, and it is important to maintain a high index of suspicion, especially in the elderly. The most common causes are Graves' disease and thyroiditis (especially postpartum), and in the elderly toxic nodular goitre and amiodarone. Patients taking amiodarone should have their thyroid function checked every 6 months. Patients with overt hyperthyroidism should be referred for specialist management; beta-blockers and sometimes anti-thyroid drugs may be initiated in primary care. Most thyroid nodules, especially those detected incidentally on ultrasound scanning, are benign. Indications for referral include newly occurring nodules >1cm in diameter, painful nodules, and nodules that are increasing in size.

The impact of supervision on stock management and adherence to treatment guidelines: a randomized controlled trial.

Ensuring the availability of essential drugs and using them appropriately are crucial if limited resources for health care are to be used optimally. While training of health workers throughout Zimbabwe in drug management (including stock management and rational drug use) resulted in significant improvements in a variety of drug use indicators, these achievements could not be sustained, and a new strategy was introduced based on the supervision of primary health care providers. This was launched in 1995 with a training course in supervisory skills for district pharmacy staff. In order to evaluate the impact of the supervision and the effectiveness of the training programme, adherence to standard treatment guidelines (STG) and stock management protocols was evaluated in a randomized controlled trial. The study compared three different groups of health facilities: those that received supervision for either use of STG (n = 23) or stock management (n = 21) - each facility acting as control for the other area of supervision - and a comparison group of facilities which received no supervision (n = 18). On-the-spot supervision by a specially trained pharmacy staff, based around identified deficiencies, took place at the start of the study and 3 months later. The evaluation compared performance on a variety of drug management indicators at baseline and 6-8 months after the second supervisory visit. The results of the study showed that, following supervision, overall stock management improved significantly when compared with the control and comparison groups. Similar improvements were demonstrated for adherence to STG, although the effect was confounded by other interventions. The study also showed that supervision has a positive effect on improving performance in areas other than those supervised, and demonstrated that pharmacy technicians with limited clinical skills can be trained to influence primary health care workers to positively improve prescribing practices. Allocating resources to supervision is likely to result in improved performance of health workers with regard to the rational use of essential drugs, resulting in improved efficiency and effectiveness.

Intermittent oral administration of potassium iodide solution for the correction of iodine deficiency.

Iodized salt and iodized oil are the main methods used to prevent iodine deficiency, but sometimes alternative approaches are needed. We tested the efficacy of various regimens for the intermittent administration of potassium iodide in Hwedza, Zimbabwe, an area of known severe iodine deficiency. We divided 304 schoolchildren aged 7-13 y into five equal groups that received iodine as a 10% solution of potassium iodide as follows: 8.7 mg every 2 wk (group A), 29.7 mg every month (group B), 148.2 mg every 3 mo (group C), 382 mg every 6 mo (group D), or 993 mg once (group E). The follow-up period was 13 mo. No adverse effects were encountered with any of these doses. After 6 mo, the median blood spot thyroglobulin concentration had decreased in all groups and had normalized in groups A and B to values found in iodine-sufficient populations. The number of children with elevated thyroid-stimulating hormone concentrations decreased in groups A-C, but the changes were not significant. Urine iodine concentration generally remained low in all groups but increased in group A. After 13 mo, mean thyroid volume measured by ultrasound had decreased in groups A and B to values comparable with those in iodine-sufficient areas, and was unchanged in the other groups. We conclude that oral potassium iodide is effective for the prophylaxis of iodine deficiency if given as a dose of 30 mg I monthly or 8 mg biweekly.

Risk factors for contracting plague in Nkayi district, Zimbabwe.

OBJECTIVE: To identify risk factors for contracting plague among the three to 16 year old age group. DESIGN: A matched case control study, carried out in two parts. SETTING: Nkayi District--a plague endemic area in Zimbabwe. SUBJECTS: A total of 86 cases were randomly selected from a line listing of all reported plague cases in the district. Two neighbourhood controls were selected from households at least 500 m on either side of the case household. MAIN OUTCOME MEASURES: Maximum likelihood estimate of the odds ratio (OR) for the 17 risk factors studied (grouped as personal, environmental, domestic animals and rat reports). RESULTS: Risk factors which were significantly associated with contracting plague were having a sick cat in the household (OR 3.4, 95% CI 1.1 to 13.0), herding cattle (OR 1.7, 95% CI 1.0 to 3.0), and age 10 years or older (OR 2.2, 95% CI 1.2 to 4.1). In a logistic model, only having a sick cat was found to be independently associated with being a case (OR 3.9, 95% CI 1.3 to 12.2). CONCLUSION: The presence of a sick domestic cat was identified as a risk factor for acquiring bubonic plague during this outbreak. Communities should be informed that sick cats may act as a warning of potential plague, and that if cats become sick they should be removed from the household.

Risk factors for sexually transmitted disease amongst men in Harare, Zimbabwe.

A cross sectional survey was carried out among adult males attending a municipal polyclinic and two private practitioner surgeries in a Harare high density suburb, in order to identify risk factors for Sexually Transmitted Disease (STD). One hundred and twenty subjects participated, of whom 83 were cases (those with STD in the past six months) and 37 were controls (those with no STD). No association of STD was found with marital status, place of residence of wife, age, level of education or employment. STD was strongly associated with alcohol consumption (Odds Ratio = 7,1 [95 pc CI: 2,8-18,7]). These results strongly suggest that alcohol consumption is an important risk factor for STD. Further work is needed to explore the relationship between alcohol consumption and high risk sexual behaviour, and to test the impact of programmes aimed at targeting the reduction of alcohol use on the transmission of HIV infection.

Psychopathology in primary care patients: a four year study in rural and urban settings in Zimbabwe.

It has been argued that prevalence rates for psychopathology in Africa are stable over time and setting. There are, however, few longitudinal studies, and these conclusions are mainly based upon point prevalence studies. It has also been observed that African patients present with somatic symptoms, a feature argued to impede detection. Furthermore, it has been argued that such multiple somatic symptoms (three or more) are diagnostic of psychopathology. The present study examined these questions in the context of a longitudinal design. Prescriptive screenings of both rural and urban primary care patients were undertaken, and repeated the following year. The measures indicate that there is no significant difference in the rates in urban and rural settings, nor any difference in the rates over time. There were few differences between cases and non-cases in demographic characteristics, but there were differences in the clinical characteristics of the two groups. Cases tended to present with more symptoms than non-cases, thus corroborating earlier findings. In addition, the symptoms of cases tended to implicate more physiological systems than non-cases.

PIP: In Zimbabwe, medical students screened 1263 adults, 16-65 years old, attending general medical clinics at Howard Hospital in Chiweshe in 1986-87 and at the Parirenyatwa Primary Care Clinic in Harare in 1988-1989 for psychological disorders. 26% had a score of at least 7 on the self-reporting questionnaire (SRQ) 20, suggesting a psychological disorder. The prevalence of psychological disorder was somewhat higher among urban patients than rural patients, but the difference was not significant (28% vs. 24%; p = .09). Prevalence did not increase with time. The mean SRQ-20 score among cases fluctuated between 9.3 and 10.6 in 1986-1989. SRQ-20 scores for anxiety, depression, and suicidal ideation among cases were basically the same through out the study period. People with some degree of psychological disorder (cases) were more likely to be unemployed (p = 0.05). Cases had a higher number of complaints or symptoms than controls (p .001). They also had more psychological symptoms implicated by the complaints than did controls (p .001). Patient complaints may steer clinicians from examining patients for psychological disorders so that they just focus on physical illness. The researchers have identified a need to develop valid and reliable instruments for good descriptive studies, for longitudinal studies examining prevalence rates of psychopathology over time, and studies comparing psychopathology in different settings.

A high prevalence of hypothyroidism in association with endemic goitre in Zimbabwean schoolchildren.

One-hundred-and-eighty-eight ostensibly normal, pubertal schoolchildren, aged 9-16 years, residing in Chinamora Communal Land, Zimbabwe, had blood taken to assess thyroid function. Total goitre rate in the area was 44 per cent in primary schoolchildren: 91 of the subjects tested were goitrous. Thyroid stimulating hormone levels (TSH) were above normal (5.0 mu/l) in 66 subjects overall, of whom 39 were goitrous. The 36 subjects with TSH levels above 7.0 mu/l also had total thyroxine (T4) estimations performed: of these, 19 were below 60 nmol/l. The results indicate a high prevalence of hypothyroidism in this at risk group. The implications of these results are discussed, notably the impairment of mental function that is likely to result.

Severe iodine deficiency in two endemic goitre areas of Zimbabwe.

The purpose of the study was to investigate the iodine status of the population and the possible role of goitregens (that are metabolised to thiocyanate), in two endemic goitre areas of Zimbabwe. This was done through estimation of iodine (I) and thiocyanate (SCN) levels in spot urine samples collected from goitrous and non-goitrous subjects. Mean and median urine iodine concentrations respectively for Wedza (n = 50) were 1.4 micrograms/dl and 1.0 micrograms/dl and for Chiweshe (n = 60) were 2.1 micrograms/dl and 1.65 micrograms/dl. The differences between the two districts are significant (P = 0.005) and mirror the overall differences in goitre rates found. Urine I levels were generally lower in goitrous than non-goitrous subjects, but the difference was not significant. Mean urine SCN concentrations and mean I/SCN ratios respectively for Wedza were 0.5 micrograms/dl and 2.9 micrograms/dl and for Chiweshe were 0.7 micrograms/dl and 3.4 micrograms/dl. These results indicate that the populations studied are affected by severe iodine deficiency, but that thiocyanate does not have a significant goitrogenic effect. The implications of the results, and the reasons for the discrepancies between them and ones obtained in earlier studies, are discussed.

Travel to hospital. Accessibility of out-patient services in rural communities.

The medical and financial advantages of centralising health services contrast with the disadvantage that they are less accessible to patients, and this is specially felt in out-patient departments. In a study based on rural Northern Ireland Norma Reid and Chris Todd looked into how patients travelled to the OPD and how long it took them. It was the socially disadvantaged--the poor, the unemployed and the retired, who did not have a family car--who were most disadvantaged by the inaccessibility of the hospital and although they were quite numerous they were probably not enough to make a commercial bus service viable.

Iodine deficiency disorders in Zimbabwe. No change in prevalence of endemic goitre in Wedza District, as shown by school surveys carried out 18 years apart.

Goitre prevalence surveys were carried out in 1986 in five primary schools in Wedza District and the results compared with those obtained from the same schools in 1968. Overall, goitre prevalence was 73 percent and there had been no significant change since 1968. In 1986 the visible goitre rate was 14 percent. Goitre was more common in girls on both occasions. Evidence (though not conclusive) of milder forms of endemic cretinism was found. The need for a nationwide iodination programme is emphasised.

Hearing in primary school children in an iodine-deficient population in Chinamhora, Zimbabwe.

Chinamhora, Zimbabwe is an area of known endemic goiter and iodine deficiency. Out of 211 primary school children living in the area who had been recruited for a study of the effects of iodine administration, 121 were randomly selected for audiometric testing. All had normal hearing. One further child already noted to have hearing difficulties was tested and found to have fairly severe bilateral nerve deafness, although this was unlikely to have been due to endemic cretinism. Urine iodine/creatinine ratios in 61 out of the 211 children were mostly in the range 50-100 micrograms/g. There is no general impairment of hearing associated with mild to moderate iodine deficiency in this population.