Effectiveness of the iodine prophylaxis model adopted in Poland.

OBJECTIVE: Most of the Polish territory has been classified as an iodine-deficient and endemic goiter area according to the International Council for Control of Iodine Deficiency (ICCIDD) criteria. In 1997 the obligatory model of iodine prophylaxis was implemented. Our investigations were aimed at the effectiveness of iodine prophylaxis in Poland. METHODS: We assessed urinary iodine excretion and goiter prevalence in 5663 children aged 6-12 yr. The population of children from the same 27 schools was investigated from 1992 to 1994 (1406 girls and 1244 boys) and from 1999 to 2005 (1563 girls and 1450 boys) using identical laboratory and ultrasound methods. RESULTS: We found significant increase in iodine urinary concentration (median 52 microg/l vs 93 microg/l, p<0.001) with accompanying drop in goiter prevalence (29.6% vs 5.2%, p<0.001) after implementation of iodine prophylaxis. Iodine excretion distribution changed significantly after 1997 with an increase in the percentage of children with iodine urinary concentration above 100 microg/l from 10.8% to 45.4%, respectively. A significantly higher iodine urinary concentration was observed in lowlands compared to uplands both before and after implementation of iodine prophylaxis (median, 50 microg/l vs 57 microg/l and 86 microg/l vs 114 microg/l, respectively, p<0.001). The goiter prevalence did not differ between girls and boys from 1992 to 1994 (28.8% vs 30.5%, p=0.35) and 1999 to 2005 (5.5% vs 4.9%, p=0.45). CONCLUSIONS: Implementation of the new model of iodine prophylaxis in Poland in 1997 has led to significant increase in iodine urinary concentration and decrease in goiter prevalence among Polish schoolchildren. In the youngest group of children (6-8 yr olds), prevalence of goiter decreased to 3.2%--i.e. below endemic levels.

Iodine deficiency disorders incidence in neonates based on the experience with mass screening for congenital hypothyroidism in southeast Poland in the years 1985-2000.

Thyroid hormones are very important for the child mental and physical development. In southeast Poland screening for congenital hypothyroidism detection was established in 1985; this region was defined as an iodine deficient area. The results provided the first signal pointing to insufficient iodine prophylaxis in the region. In the years 1985-2000, a total of 634,179 newborns were tested. TSH levels in blood spots on filter paper were determined using three consecutive methods: RIA, fluoroimmunometry (FIA) and luminoimmunemetry (LIA). In the first five years of the program, the incidence of permanent hypothyroidism was 1:4,000, while the incidence of iodine deficiency disorders (IDD) was 1:272. These findings led to the recognition of the fact that iodine prophylaxis had been discontinued in 1981 and reintroduced in 1992 and from that time on the incidence of IDD in neonates has been evidently lower. In the period between 1991 and 2000, we observed a 0.14% incidence rate of IDD, while until 1991 it had been 0.5%. In the years 1998-2000, the respective value was 1:5,420. The incidence of transient hypothyroidism also dropped from 1:3,920 to 1:48,474. Therefore we conclude that, based on screening studies carried out since 1985, the analysis of TSH levels may be regarded as a tool for iodine deficiency monitoring in neonates. Between 1985-2000, a drop in the incidence of IDD in newborns is clearly seen. Moreover, investigations carried out in particular years show that even low-grade iodine supplementation leads to TSH level decrease in newborns.

Natural history of asplenism in APECED--patient report.

Only a few reports on patients with hypo/ asplenism associated with APECED have been published, yet hyposplenism has been found in approximately half of the studied patients. The 7-year follow-up in our only patient with APECED revealed a decrease of spleen size from normal to half-size by ultrasound and CT examinations. Scintigraphy of the liver and spleen demonstrated a progressively diminishing splenic uptake of the tracer from low to complete absence. Peripheral blood smears revealed permanent thrombocytosis with the presence of Howell-Jolly bodies when functional asplenism was reached. The cause of autoimmunization and hyposplenism in APECED is unknown. We hypothesize that hyposplenism depends primarily on local AIRE gene dysfunction in the spleen, and secondarily on an AIRE gene-mediated autoagressive process. In our opinion, hypo/asplenism in APECED disease might not be noticed in patients with APECED if not directly examined. Thus we emphasize the necessity of searching for hyposplenism in all patients with APECED, and recommend scintigraphy.

A programme of iodine supplementation using only iodised household salt is efficient--the case of Poland.

BACKGROUND: Iodine prophylaxis in Poland started in 1935 and has been interrupted twice: by World War II and in 1980 for economic reasons. Epidemiological surveys carried out after the Chernobyl accident in 1989 as well as in 1992/1993 and in 1994 as a 'ThyroMobil' study, revealed increased prevalence of goitre in children and adults. Ninety per cent of Poland was classified as an area of moderate iodine deficiency, and 10%, in the seaside area, as mild iodine deficiency territory. Iodine prophylaxis based on iodisation of household salt was introduced again in 1986 as a voluntary model and in 1997 as a mandatory model with 30+/-10 mg KI/kg salt. OBJECTIVE: The evaluation of the obligatory model of iodine prophylaxis in schoolchildren from the same schools in 1994 and 1999. METHODS: Thyroid volume was determined by ultrasonography. Ioduria in casual morning urine samples was measured using Sandell-Kolthoff's method, within the framework of the ThyroMobil study. RESULTS: Goitre prevalence decreased from 38.4 to 7% and urinary iodine concentration increased from 60.4 to 96.2 microg/l mean values between 1994 and 1999. In four schools the prevalence of goitre diminished below 5%. In 1999, 70% of children excreted over 60 microg I/l, and 36% over 100 microg I/l, whereas in 1994 the values were 44 and 13% respectively. CONCLUSION: The present findings indicate that iodine prophylaxis based only on iodised household salt is highly effective.

Mass screening program for congenital hypothyroidism in south-eastern Poland.

The success of a screening program depends in great measure on effective organization. The purpose of the screening program is the commencement of treatment of selected patients within two weeks of life. In total in our laboratory we have tested 461,479 newborns during 1985-1996. The introduction of bar codes in 1995 (recommended by the Institute of Mother and Child in Warsaw) improved our work in the laboratory and departments of obstetrics and reduced the possibility of errors. The screening tests for congenital hypothyroidism appear to serve the monitoring of iodine deficiency disorders. The good organization of the screening program is indispensable and needs permanent control.

[Anorexia nervosa and its clinical variations--a hormonal and behavioral paradigm]. / Anoreksja nerwowa i jej odmiany kliniczne--paradygmat behawioralno-hormonalny.

The authors presents the regulatory role of endocrine system in children and adolescents with anorexia nervosa. The psychological and behavioral symptoms, being the main cause of the illness, need a prompt recovery. For that reason, the therapeutic activity of psychologist and psychotherapist in the family therapy center is fundamental for the patient. Pediatrician's and endocrinologist's task is to establish the diagnosis, reinstate the metabolic balance, if need is, and prevent the late consequences especially those of reproductive system of the patient.

[Sporadic generalized insensitivity of peripheral tissue receptors to thyroid hormone in a 15 year old boy]. / Sporadyczna uogólniona niewrazliwosc receptorów tkanek obwodowych na hormony tarczycy u 15-letniego chlopca.

Sporadic generalized form of insensitivity to thyroid hormones of peripheral tissue receptor was proposed as diagnosis in a clinically euthyroid boy 15.5 years old with goiter, having elevated levels of blood serum triiodothyronine (T3) and thyroxine (T4) associated with absence of TSH suppression. Other possible causes of biochemical hyperthyreosis were excluded by differential diagnosis. The results of functional examination of cardiovascular system by the method of Hauffa could be interpreted only as a lack of response of tissue receptors to the administration of triiodothyronine, also when used in pharmacological doses. Lower response of pituitary to the administered triiodothyronine was demonstrated by applying the TRH stimulation test. No antithyroid treatment was applied in accordance with the data from the literature. In long-term observation (above 1.5 year) clinical state of the boy was still good a gradual increase in growth rate and progress in sexual maturation being noted.

Thyroid dysfunction in newborns and infants living in an iodine-deficient area.

The region of Southern Poland is known as an iodine-deficient area. Iodine prophylaxis was discontinued in 1980/81. This fact was discovered as a result of the introduction of newborn mass screening for congenital hypothyroidism in 1985. In view of the large number of newly detected cases of Iodine Deficiency Disorders (IDD), we compared the neonatal populations of the Cracow and Nowy Sacz provinces. The prevalence of IDD was revealed as eight times higher in Nowy Sacz than in Cracow. The iodine urine excretion rates in those two provinces were similar. The paper discusses the cause of the discrepancy in IDD incidence. The final results show that the iodine deficiency detected in the Cracow and Nowy Sacz provinces is of moderate degree. Salt iodination in the region of southern Poland needs a new approach even before the year 2000, as planned in the WHO program.

Principles, main goals and methods of the nationwide program: "investigations on iodine deficiency and model of iodine prophylaxis in Poland".

The main reasons to start investigations on IDD in Poland as a nationwide project of the Ministry of Health and Welfare sponsored by the State Committee For Scientific Research and Foundation for Polish Science were: cessation of iodizing of kitchen salt in Poland in 1980, increase of the incidence of goitre in the population and hyperthyrotropinemia in newborns, results of the survey undertaken after Chernobyl disaster indicating an increase of goiter incidence (Nauman et al.) and results of the pilot study (Gutekunst, Gembicki, Kinalska and Rybakowa) indicating an increase of thyroid volume and diminishing of iodine excretion in urine of children in Kraków, Bialystok ad Poznan regions. Therefore the main goals of the project were as follows: to evaluate IDD in Poland on the population basis, to map goiter incidence and iodine deficiency in geographic areas, to evaluate a voluntary model of iodine prophylaxis in Poland (20 mg of KI/kg of salt). The investigations were carried out in 19330 children (48.7% of boys and 51.3% for girls) in age group 6-13 years, attending 111 coeducational randomly selected schools from all the country. This number represents 0.35% of children subpopulation in the above age-groups. For practical purposes local coordinating centers at the relevant Departments of Endocrinology and Board of Coordinators were set up. The programme of survey included: filling the questionnaire by children's parents, thyroid palpation and classification according to WHO and ICCIDD criteria, thyroid volume determination by means of ultrasonograph Kontron Sigma 1 L with linear transducer 7.5 MHz, determination of iodine in casual morning urine sample using Sandell and Kalthoff method. Determination of iodine concentration in urine was performed in each case of goiter and in the same number of children without goiter. The results were segregated according to coordinating centers and according to 6 geographical areas of the country. The results were calculated according to the descriptive statistics using Student's test, Chi-square test F-test and Leven's test. The results segregated according to geographic areas were tested by means of analysis of variance using the linear model. The final results of the programme are presented in the next papers.

Goiter incidence and urinary iodine excretion in children of age group 6-13 years living in south-eastern Poland (Kraków coordinating center).

The study included 4103 school children attending randomly selected schools localized in towns and villages of 3 geographically distinct regions: mountainous, (Carpathian endemia), upland, lowland. The children were divided into four age-related groups. The incidence of goiter as detected by palpation was 38.1% in all the children studied, the value being similar in all three regions (38.1, 37.3 and 38.6%, respectively). Goiter incidence differs slightly among urban and rural children, amounting to 40.5 and 34.5%, respectively, in the two groups. In about 60% of children urinary iodine excretion was lower than 50 micrograms/l, while in about 30% it was normal. In about 10% of children studied urinary iodine excretion was lower than 20 micrograms/l. The results obtained indicate the occurrence among children of the studied region of goiter endemy of moderate degree. It was found that the percentage of children excreting more than 50 micrograms/l of urinary iodine was higher among those consuming iodized salt as compared to those consuming non-iodized salt. The first effects of resumption of common salt fortification with iodide in southern Poland can already be noted. There is, however, a need for optimization and steady control over this prophylactic action.

[Incidence of goiter in children of the Tarnobrzeg district and environmental factors]. / Czestosc wystepowania wola u dzieci w województwie tarnobrzeskim a czynniki srodowiskowe.

A group of 1897 school children from Tarnobrzeg district were examined out of this number 1241 (65.4%) children displayed goiter. Goiter incidence was also established depending upon age and sex. The analysis also included goiter incidence in relation to its size according to the WHO classification. In certain patients, newborns and their mothers, determinations of iodine excretion were made; the values were found to be within the normal. This range suggests that other etiological factors than iodine deficiency might possibly contribute to goiter development in the studied children.

[Dietary iodine intake in children and clinical and biochemical features of iodine deficiency in chosen districts of south-east Poland]. / Spozycie jodu w pokarmach dzieci a kliniczne I biochemiczne cechy niedoboru jodu w wybranych województwach Polski Poludniowo-wschodniej.

The study on the effects of Czarnobyl accident on thyroid gland function in children (MZ XVII program) revealed a high incidence of goiter in the population of children in district Kraków and Nowy Sacz. Other study on Tarnobrzeg population showed that the frequency of goiter in school children was 67%. The goiter prevalence, urine iodine excretion and iodine food consumption in the same populations were compared. The detailed investigation of iodine intake in children by feeding questionnaire shows a low consumption of iodine. The urine iodine excretion in the population of Kraków-district was low, but higher than in Nowy Sacz-district and nearly normal in Tarnobrzeg. High frequency of goiter in children and of IDD in newborns screened for CH, as well as low urine iodine excretion, together with low iodine intake with food are the markers of iodine deficiency in Kraków and Nowy Sacz districts. The improvement of feeding as well as iodine salt supplementation is necessary. The situation in Tarnobrzeg district looks differently and needs additional study.

[Study on consequences of radioactive iodine pollution and iodine prophylaxis after the Czernobyl accident in the Krakow region]. / Badania nad skutkami skazenia jodem radioaktywnym i profilaktyki jodowej podjetej w wyniku awarii w Czarnobylu w regionie krakowskim.

Program of investigations of effects of radiation and iodine prophylaxis undertaken after Czarnobyl accident in Kraków region had to be modified due to goiter endemy in this region. These modifications included: 1) Division of the region into 3 areas (voivodship Nowy Sacz, urban voivodship Kraków and area of Kielce and Swietokrzyskie mountains). 2) Study on iodine uptake in food and urinary secretion. 3) Examination of iodine level in drinking water, add an attempt of calculation of radiation dose absorbed by thyroid. Characterization of selected areas, principles of selection of study groups are presented as well as organizational details and methods of data collection.

[Epidemiologic studies after the disaster in Czernobyl in the population of children in the Krakow region]. / Badania epidemiologiczne po awarii w Czarnobylu w populacji dzieci w regionie krakowskim.

In 1989-1990 the epidemiologic studies about the impact of of Czarnobyl events on the health of children in Kraków and Nowy Sacz region were performed. The morphologic and functional changes of thyroid gland in children were estimated. Almost 90% of children in both districts received the iodine preparations for prophylactic reason. The mean time of intake was between 5-10 days following the Czarnobyl explosion. There were no relationship between the dose of iodine absorbed during prophylactic action and incidence of goiter. The prevalence of goiter amounted to 34.8-47.6% in boys and girls consecutively in Kraków district and 53.8-70.5% in Nowy Sacz. No hormonal changes in T3, T4 and TSH serum concentration were found in children with goiter and those without goiter. The complications after iodine intake were transient and seen only in a small number of children.

[Clinical and morphological picture of adrenal gland carcinoma with characteristics of early embryonal development]. / Kliniczny i morfologiczny obraz raka nadnerczy z cechami rozwoju wczesnozarodkowego.

A two year old girl with symptoms of virilization was investigated and an adrenal gland tumor with morphological sings of malignancy was diagnosed. After surgery, irradiation and chemotherapy, a complete recovery was observed. The authors point out the diagnostical difficulties in similar cases. Our observation seems to confirm earlier suggestions, that in cases with predominant androgen activity the better prognosis is expected.

[Adipose tissue distribution in children with excessive body weight and the possibility of development of complications of obesity. II. Positive family history in relation to arteriosclerosis risk factor and the constitutional type of obesity in children]. / Rozmieszczenie tkanki tluszczowej u dzieci z nadmiarem masy ciala a mozliwosc wystepowania powiklan otylosci. Czesc II. Obciazajacy wywiad rodzinny w odniesieniu do czynnika ryzyka miazdzycy a typ konstytucjonalny otylosci u dzieci.

98 children with simple obesity were investigated. The prevalence of cardiovascular diseases (hypertension, coronary heart disease including heart infarction, disturbances of the cerebral circulation) and diabetes in parents and relatives of the obese children have been evaluated. The relation between the type of obesity (androidal, gynoidal) and the prevalence of the above complications in the family history was assessed. No correlation between the type of obesity and the mentioned diseases was observed.

[Adipose tissue distribution in children with excess body weight and possible complications of obesity. I. Evaluation of an index (waist to hip circumference) in children with simple obesity]. / Rozmieszczenie tkanki tluszczowej u dzieci z nadmiarem masy ciala a mozliwosc wystepowania powiklan otylosci. Czesc I. Ocena wskaznika (obwód pasa do obwodu bioder) u dzieci z otyloscia prosta.

Distribution of the fat tissue has been estimated in 94 children with simple obesity and in 100 children with normal parameters of the somatic development. The relation of waist measurement (at the navel level) to the hip measurement (at the level of sacral bone) (p/b) was evaluated. This ratio was higher in the group of the obese than in the normotensive children. Higher values of the waist measurement can indicate an excessive fat tissue deposition in the epigastrium. This is a poor prognostic factor as it indicates the greater risk of complications of obesity. This children should be followed up.