[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.

Zinc status and relation to thyroid hormone profile in Iranian schoolchildren.

Zinc is an essential element involved in many basic biochemical reactions in thyroid. However, little is known about concentration of this mineral in goitrous Iranian schoolchildren. This study was undertaken to determine the prevalence of zinc deficiency and the current zinc status in goitrous schoolchildren. A cross-sectional study in which 1188 schoolchildren in the age group of 8-13 years were evaluated for goiter prevalence, urinary iodine and zinc status. Zinc measurement was performed by atomic absorption spectrometry apparatus and urinary iodine was measured by digestion method. Goiter was graded according to WHO classification and serum concentration of thyroid hormones and thyroid-stimulating hormone were determined by commercial kits. This study showed an adequate iodine supply. Eleven percent of all cases had low zinc levels and the mean serum zinc concentration was 84.1 +/- 20.7 microg/dl with a significant difference between the boys and girls (86.6 +/- 22.7 microg/dl vs. 82 +/- 18.7 microg/dl, p = 0.017). The mean concentration in goitrous children was 85.1 +/- 23 microg/dl and for those without goiters was 82.6 +/- 16.7 microg/dl which was not statistically significant. No significant difference was noticed between those with low and normal zinc levels in the prevalence of goiter. In view of normal iodine status, other goitrogenic factors should be evaluated to explain the residual goiter prevalence.

Iodine nutritional status among school children in selected areas of Howrah District in West Bengal, India.

This article is a study on iodine nutritional status among 1627 school children aged 6-12 years, along with biochemical analysis of iodine of 200 urine samples, 50 drinking water samples and 175 salt samples carried out in certain randomly selected areas of the district Howrah in Gangetic West Bengal. Results indicate that the entire region is clinically goitre endemic having goitre prevalence 38%; however the median urinary iodine level was 25 microg/dl indicating no biochemical iodine deficiency, 70% salt samples had a recommended level of iodine and the region was found to be environmentally iodine sufficient. Consumption of dietary goitrogen and hard drinking water may have the possible role for the persistence of endemic goitre in the region.

The goitre rate, its association with reproductive failure, and the knowledge of iodine deficiency disorders (IDD) among women in Ethiopia: cross-section community based study.

BACKGROUND: Iodine deficiency is severe public health problem in Ethiopia. Although urinary iodine excretion level (UIE) is a better indicator for IDD the goitre rate is commonly used to mark the public health significance. The range of ill effect of IDD is however beyond goitre in Ethiopia. In this study the prevalence of goitre and its association with reproductive failure, and the knowledge of women on Iodine Deficiency were investigated. METHODS: A cross-section community based study was conducted during February to May 2005 in 10998 women in child bearing age of 15 to 49 years. To assess the state of iodine deficiency in Ethiopia, a multistage "Proportional to Population Size" (PPS) sampling methods was used, and WHO/UNICEF/ICCIDD recommended method for goitre classification. RESULTS: Total goitre prevalence (weighted) was 35.8% (95% CI 34.5-37.1), 24.3% palpable and 11.5% visible goitre. This demonstrates that more than 6 million women were affected by goitre. Goitre prevalence in four regional states namely Southern Nation Nationalities and People (SNNP), Oromia, Bebshandul-Gumuz and Tigray was greater than 30%, an indication of severe iodine deficiency. In the rest of the regions except Gambella, the IDD situation was mild to moderate. According to WHO/UNICEF/ICCIDD this is a lucid indication that IDD is a major public health problem in Ethiopia. Women with goitre experience more pregnancy failure (X2 = 16.5, p < 0.001; OR = 1.26, 1.12 < OR < 1.41) than non goitrous women. Similarly reproductive failure in high goitre endemic areas was significantly higher (X2 = 67.52; p < 0.001) than in low. More than 90% of child bearing age women didn't know the cause of iodine deficiency and the importance of iodated salt. CONCLUSION: Ethiopia is at risk of iodine deficiency disorders. The findings presented in this report emphasis on a sustainable iodine intervention program targeted at population particularly reproductive age women. Nutrition education along with Universal Salt Iodization program and iodized oil capsule distribution in some peripheries where iodine deficiency is severe is urgently required.

The role of iodine in the evolution of thyroid disease in Greece: from endemic goiter to thyroid autoimmunity.

The thyroid gland is dependent on dietary iodine for the production of thyroid hormones, normal iodine requirement being about 150-200 microg/day. Long-term deficiency in iodine intake is associated with the development of goiter. When the prevalence of goiter in a population rises above 5-10%, the problem is considered endemic. Greece is a country with a recent history of moderate iodine deficiency, endemic goiter being prevalent in the 1960s in inhabitants of mountainous regions. Despite recognition of the problem, an iodine prophylaxis program was never officially implemented. Instead, "silent iodine prophylaxis" took place during the 1980s and 1990s with Greece's improvement in socioeconomic conditions. This resulted in the elimination of iodine deficiency and a parallel decrease in the prevalence of goiter among schoolchildren in formerly iodine deficient areas. However, the transition from iodine deficiency to iodine sufficiency or excess was followed by the emergence of autoimmune thyroiditis, especially among young girls, indicating that exposure to excess iodine may trigger thyroid autoimmunity. Thus, the modification of an environmental factor, ie dietary iodine, over the last 40 years in Greece has been associated with changes in the phenotypic expression of thyroid disease from endemic goiter to goiter associated with autoimmune thyroiditis.

Tiroiditis de Hashimoto en niños y adolescentes con bocio / Hashimoto´s thyroiditis in children and adolescents with goiter

Se denomina bocio al aumento de tamaño de la glándula tiroidea, que da lugar a un abultamiento en la región anterior del cuello, el agrandamiento de los lóbulos laterales de la tiroides debe ser superior al tamaño de la falange distal del dedo pulgar del paciente. La tiroiditis de Hashimoto es la inflamación crónica de la tiroides de origen autoinmunitario; cursa con bocio y puede provocar hipotiroidismo existe un hipotiroidismo, este se desarrolla en forma paulatina. El tratamiento del paciente hipotiroideo consiste en la administración de levotiroxina.

Urinary iodine and other iodine deficiency indicators in a sample of school-age children in Egypt.

Sufficient data relating urinary iodine excretion in children to other iodine deficiency indicators are lacking in Egypt. We assayed urinary iodine concentration and serum levels of thyroid stimulating hormone (TSH), thyroglobulin, free triiodothyronine (T3) and free tetraiodothyronine in 99 school-aged Egyptian children. Goitre was found in 25 children. Median urinary iodine concentration was 70 microg/L. We found mild iodine deficiency (50-99 microg/L) in 60.6 % of the children and moderate to severe deficiency (< 50 microg/L) in 31.3%. The latter showed a high frequency of goitre and elevated mean serum free T3, TSH and thyroglobulin levels. Individual urinary iodine excretion rates vary, therefore these other indicators could help in screening for iodine deficiency at an individual level, especially in moderate to severe deficiency.

Classification of thyroid size by palpation and ultrasonography in field surveys.

BACKGROUND: Goitre surveys are used to assess the degree of iodine deficiency in a population. The change of goitre classification made by WHO in 1994 implied that a smaller thyroid size should be regarded as goitre. Furthermore, the acceptable goitre prevalence was lowered from 10% to 5%, and ultrasonography was recommended as a more precise method for diagnosis of goitre. We studied the effects of the change of palpation system, and compared the precision of the old and new systems with that of ultrasonographic examination. METHODS: We studied 225 schoolchildren (aged 7-14 years) in a highland village in Tanzania. The size of the thyroid was assessed in duplicate by ultrasonography and by WHO's 1960 and 1994 palpation systems. The latter were done by three examiners. Variations within and between examination methods and examiners were assessed, and measurement errors by ultrasonography were assessed from duplicate examinations. The sensitivity and specificity of the two palpation systems were calculated, with diagnosis by ultrasonography as the gold standard. Apparent palpation prevalences were calculated at a "true" 5% prevalence. FINDINGS: The lowered criterion for goitre resulted in an extra 20-33% of children being diagnosed as having goitre by palpation. The variation between repeat examinations was only slightly smaller by ultrasonography (kappa=0.63) than by experienced examiners (kappa=0.57-0.58). The variation between thyroid volume estimation by ultrasonography and the true volume was about 50% due to both measurement error and variation in the shape of thyroid lobes. The new goitre criterion decreased specificity from 76% to 29%, whereas sensitivity rose from 56% to 80%. In contrast, a suggested sharpening of the old criterion increased specificity to 90%. INTERPRETATION: A return to the old (1960) palpation criterion for goitre: "lobes larger than the terminal phalanxes of thumbs" and to an accepted palpation goitre prevalence of 10% can allow affordable monitoring of thyroid size through palpation in field surveys.

Short-term effectiveness of mandatory iodization of table salt, at an elevated iodine concentration, on the iodine and goiter status of schoolchildren with endemic goiter.

BACKGROUND: Goiter rates and iodine deficiency usually show marked improvement in efficacy studies of mandatory iodization of salt, but little is known about the short-term effectiveness of mandatory iodization. OBJECTIVE: The aim of the study was to evaluate, after 1 y, the effectiveness of mandatory iodization of salt at an iodine concentration higher than that occurring under optional iodization on the goiter rates and iodine status of schoolchildren living in an endemically goitrous area. DESIGN: Goiters, measured by palpation, and urinary iodine concentrations of children in grades 4-7 in 4 schools in a known goitrous area in South Africa were assessed before and 1 y after the introduction of mandatory iodization at a higher iodine concentration than occurred with optional iodization. Estimates of the iodine concentration of iodized salt and the proportion of households using iodized salt were also made. RESULTS: Iodine concentration in table salt and household use of iodized salt improved within 1 y. Goiter rates, which varied at baseline from 14. 3% to 30.2% in the 4 schools, remained unchanged, with an overall mean (+/-SE) prevalence of 25.6 +/- 2.5% at baseline and of 27.5 +/- 2.7% 1 y later. The distribution of urinary iodine concentrations in the 4 schools improved substantially from the baseline deficient range. The overall median urinary iodine concentration increased from 0.17 to 1.47 micromol/L. CONCLUSIONS: Mandatory iodization of salt virtually eradicated iodine deficiency within 1 y in South African schoolchildren, but the goiter rate in these children did not decline. Measurement of goiters by palpation may not be appropriate in short-term evaluations of mandatory iodization programs.

Elevated anti-galactosyl antibody titers in endemic goiter.

Anti-Gal is a human polyclonal antibody that constitutes approximately 1% of the circulating immunoglobulin G (IgG), interacts specifically with the mammalian carbohydrate alpha-galactosyl epitope. Furthermore, it was found to mimic in vitro thyrotropin (TSH) effects regarding stimulation for cyclic adenosine monophosphate (cAMP) synthesis, 125I uptake, and cellular proliferation on cultured porcine thyrocytes and on Graves' disease thyrocytes, but not on normal human thyrocytes. As immune activation in sporadic and endemic goiters might play a secondary role in regulating thyrocyte proliferation and function, we evaluated anti-Gal titers in endemic goiter. Serum was obtained from 109 Chagas'-negative patients living in an endemic goiter area of Brazil (Grao Mogol, MG) and 160 controls. The patients were divided into 3 groups, according to their goiter size (World Health Organization [WHO] classification): grade 0 (group 1, n = 24), grade I-II (group 2, n = 41), and grade III-IV (group 3, n = 44). Anti-Gal was assessed by a radioimmunological procedure (results expressed as the percentage of bound radioactivity/total activity [%B/T]). The antibody titer was significantly more elevated in group 1 (mean +/- SEM: 9.27%+/-0.80%), in group 2 (mean +/- SEM: 16.17%+/-0.97%), and in group 3 (20.97%+/-1.30%) than in normal controls (6.46%+/-0.33%). Analysis of the male and female data separately for anti-Gal titer did not substantially alter these results. We concluded that the anti-Gal titer is higher in patients with endemic goiter and presented a possible relationship with the size of goiter. Whether these antibodies contribute to the pathogenesis of the disease needs further clarification.

[Management strategies for endemic goiter in developing countries]. / Stratégies de prise en charge d'une endémie goitreuse en situation de développement.

Despite significant progress in the last decades, endemic goiter remains a serious public health problem in the developing world, especially in Africa. Even in countries that have successfully reduced overall incidence to acceptable levels, endemic areas often remain. This persistence is due to the inadequacy of preventive measures and poor follow-up of control programs. The main etiologic factor in endemic goiter is inadequate dietary intake of iodine. This commonly occurs in communities depending exclusively on local produce grown on iodine-poor land, especially in mountain areas. Endemic goiter is epidemiologically associated with cretinism, deaf-mutism, and mental retardation. Even mild iodine deficiency leads to clinical hypothyroidism and moderate myxoedema with significantly reduced intellectual performance. Prevention of endemic goiter depends mainly on increasing the iodine intake of people in endemic areas. When iodine intake reaches the estimated adult minimum requirement (100 to 150 micrograms per day), the prevalence of goiter decreases. Two approaches have been used to increase iodine intake. The first consists of adding iodine to food staples such as table salt. The second consists of medical treatment using agents such as iodized oil. Iodization or iodination of salt is the most widespread and cost-effective method of prevention. Administration of iodized oil has been used only in severely endemic areas and in regions where reliable provision of iodinized salt is prevented by geographical barriers or political factors. However, iodized oil has been helpful in the start-up phase of prevention programs using iodized salt, either as an emergency measure or as a mean of convincing officials of the efficacy of iodine prophylaxis.

The influence of iodine deficiency on the cognitive performance of school children in Saki, south-west Nigeria.

The influence of inadequate iodine intake on the thyroid status and cognitive performance of school children in Saki, a town within the goitre belt of South-western Nigeria with known environmental iodine deficiency, was assessed. One hundred and ninety-seven (197) study subjects from Saki and seventy (70) appropriately matched control subjects from Moniya, near Ibadan, the Oyo State capital were recruited into the study. The subjects were apparently healthy primary school pupils between the ages of 10 and 14 years and had been resident in the respective locality for at least two (2) years. After establishing the presence of goitre, blood was collected for thyroid function tests by venepuncture from each pupil. The cognitive function tests, Draw-A-Person (DAP) test and the Standard Progressive Matrices (SPM) were administered simultaneously to all the pupils in the class. Urine samples were collected for urinary iodine estimation. The mean urinary iodine concentration was significantly lower in Saki than in Moniya (134.81 +/- 69.86 vs 220.00 +/- 69.00 ug/L, P < 0.01). The total goitre rates (TGR) and the visible goitre rates (VGR) were 15.2% and 1.5% for Saki, and 8.6% and 4.3% for Moniya, respectively. The mean plasma total T4 was significantly lower in Saki pupils (97.55 +/- 26.64 nmol/L vs 122.52 +/- 26.51 nmol/L P < 0.05). The TSH level was higher in Saki pupils than in Moniya pupils (4.72 +/- 1.38 mU/L vs 4.26 +/- 1.28 mU/L), but the difference was not statistically significant. Scores on intelligence function tests (DAP and SPM) were lower for Saki pupils when compared with Moniya pupils, though the differences were not statistically significant. These results show that there is a mild but significant iodine deficiency disorder problem in Saki. However, the children in Saki still maintained euthyroidism and the mild degree of iodine deficiency did not seem to have adversely affected their cognitive performance.

Prevalence of goitre in the southern mountainous regions of Bulgaria, 1986-1989.

Iodine supplementation programmes began in designated high risk mountainous districts in Bulgaria in 1958. The prevalence of goitre fell. But the programmes became less effective and by the mid 1980s there were strong indications that goitre was resurgent. Ten villages that had been surveyed in 1956 and 1974 were re-surveyed between 1986 and 1989. All persons available were examined (not just residents)--at home, workplace or school--by a trainee or specialist endocrinologist. Goitres were graded according to the WHO/ICCIDD system. 2,901 females and 1,885 males were examined. Diffuse, stage 1 enlargements were common in males and females under 35, with prevalences exceeding 20% in several age/sex groups. Nodular stage 1 and 2 enlargements became commoner at ages above 45, with prevalences exceeding 15% in females over 55. Overall prevalences were 28% in females and 14% in males. 6 cretins were identified. In recognised endemic areas of Bulgaria, epidemiological surveillance of IDD should be maintained. Detailed studies are required to determine why iodine supplementation became less effective after the mid 1970s and to develop and test new, cost-effective public health strategies appropriate to the changed socio-political circumstances.

Endemic goitre in rural South Delhi.

One thousand and seventy-five children from the schools of 4 villages of rural South Delhi were clinically assessed for anatomical enlargement of thyroid gland. Goitre was graded according to WHO classification. One hundred and seventy-two children showed various grades of goitre giving a prevalence of total goitre in school children to be 16%. The problem of visible goitre (grades 2 and 3) was minimal and overwhelming majority of goitre cases belonged to lower grades. Though previous school goitre surveys from urban school children in Delhi give a prevalence as high as 55.2%, the prevalence of 16% in the present survey still categorizes rural South Delhi as mild endemic according to WHO/International classification for control of iodine deficiency disorder (ICCIDD) criteria. In Delhi partial supply of iodised salt commenced, with effect from, 1-1-1984 and it was covered by 'Ban Notification-PFA Act' prohibiting the sale of sub-optimally iodised salt. There is a need for an area specific assessment of iodine deficiency disorder (IDD) and people's access to optimally iodised salt.

Indicators to monitor progress of National Iodine Deficiency Disorders Control Programme (NIDDCP) and some observations on iodised salt in west Bengal.

Iodine Deficiency Disorders (IDD) are widely prevalent in our country and their consequences for human development are well known. The scope of National Goitre Control Programme (NGCP) launched in 1962 was expanded and the programme was renamed as National Iodine Deficiency Disorders Control Programme (NIDDCP) to connote wider implications of iodine deficiency in population. It is necessary to monitor the progress of NIDDCP using quantifiable indicators to ensure achievement of programme objectives. Prevalence of iodine deficiency disorders, status of iodised salt and level of knowledge. Attitude & practice (KAP) of community regarding IDD and iodised salt are a few such indicators. Children in the age group of 8-10 years are considered most appropriate target group to monitor IDD prevalence. The quality of iodised salt assessed at various levels in West Bengal (using field testing kit) indicated 'satisfactory' iodine content (i.e. > or = 15 ppm) at wholesalers (84.3 per cent), retailers (74.3 per cent) and consumers (71.2 per cent) level. It is suggested that the quality of iodised salt should be periodically assessed and intensive educational campaigns on IDD be launched to create increased demand for consumption of iodised salt in the community.

PIP: In India, the goal of the National Iodine Deficiency Disorder Control Programme (NIDDCP) is elimination of iodine deficiency disorders (IDD) by 2000. It aims to supply iodized salt to all of India and to assess the impact of the supply of iodized salt. Quantifiable indicators used to monitor its progress include the prevalence of IDD, iodine content of salt, and knowledge, attitudes, and practices (KAP) regarding iodized salt. The program targets school children 8-10 years old for assessing IDD prevalence. It prefers the community-based survey to the school-based survey, since the former includes children not enrolled in school. The indicators health workers use to assess IDD prevalence are thyroid size (palpation and ultrasonography), urinary iodine, and level of thyroid-stimulating hormones in serum. Spot testing kits and iodometric titration method are used to measure iodine content in salt. Salt with at least 15 ppm iodine is classified as satisfactory. A goiter survey requires a minimum of 5 salt samples (about 20 g). The KAP survey needs a minimum of 5 different households in each cluster site. Issues related to salt addressed in the KAP survey include existence of iodized salt, importance of iodized salt consumption, consequences of IDD (e.g., poor physical and mental growth of children, still births, cretinism), packaging of iodized salt, price, storage of iodized salt, use of bagara salt, prior washing of salt, and source of iodized salt. In West Bengal, only iodized salt can be sold. In 1994, West Bengal met its annual requirement of edible salt. A survey at rake unloading points in West Bengal in 1994 revealed that most salt from Gujarat had adequate iodine levels, while all but 5.3% of the salt from Rajasthan had insufficient iodine levels. Health workers and food inspectors in West Bengal routinely monitor different districts at various levels (household, retailers, and wholesalers). In 1995, 84.3% of samples at wholesalers, 74.3% at retailers, and 71.2% at households had satisfactory levels of iodine. The Goitre Cell of the West Bengal government has an IDD educational program involving teachers and panchayats.

Características actuales del bocio endémico en tres zonas censoras de Chile / Curret characteristics of endemic goiter in three censor areas of Chile

El objeto del estudio fue evaluar el estado actual del bocio endémico (BE) en Chile. se estudiaron 3500 escolares de educación básica, de 6 a 16 años de edad en 3 zonas censorias del país: 1000 en Calama (Norte), 1000 en Temuco (Sur) y 1500 en Santiago (Centro). Se determinó el nivel socieconómico (NSE) por la escala de Graffar; dos examinadores entrenados determinaron por palpación la presencia y tipo de bocio de acuerdo con la clasificación de la OMS. En 20 por ciento de los escolares se tomó una muestra de la primera orina de la mañana para la determinación de yodo. Se recolectaron muestras de sal en las 3 regiones para medir su concentración de yodo. Encontramos una prevalencia de bocio de 11,4 por ciento en escolares de sexo masculino y 12 por ciento en el sexo femenino, existiendo diferencias significativas por región y siendo el bocio Ia, el más frecuente. Se observó un aumento de la prevalencia en las edades puberales en los escolares de sexo femenino. Se encontró una mayor prevalencia en los niveles medio-bajo (12,4 por ciento y 14,4 por ciento respectivamente). La calidad de la yodación de la sal fue variable en las 3 zonas, teniendo 1/3 de las muestras una concentración > de 100 partes por millón (ppm), 1/3 entre 60 y 100 ppm y 1/3

Prevalencia de bocio en varones de 18 años en la provincia de Neuquen, 1991 / Prevalence of goiter in 18 years old males in Neuquen province

El bocio endémico, causa de disminución del desarrollo físico y mental, cretinismo, sordera y mudez, es un problema de salud pública, que ha sido identificado en la Argentina en áreas montañosas del noroeste ya desde fines del siglo XIX. Su prevención mediante yodación de la sal de mesa se inició en la provincia de Mendoza en 1953, y en 1964 se creó el Plan Nacional de Prevención en el Ministerio de Salud. En 1965 se realizó el primer estudio epidemiológico con cobertura nacional en 9 provincias, en nuestra probabilísticas de varones jóvenes durante el examen médico de aptitud para el Servicio Militar. Se hallaron tasas de sprevalencia cercanas a 50 por ciento en áreas tales como la provincia montañosa del Neuquén en la Cordillera de los Andes y en Corrientes, llanuras rodeadas por grandes ríos. La yodación de la sal de mesa se hizo obligatoria por ley en 1967 y alcanzó una amplia cobertura en 1970. Después de 24 años de uso continuo de la sal enriquecida se realizó un nuevo estudio para evaluar la evolución de la endemia en varones jóvenes en Neuquén en 1991 y en Corrientes en 1992, con métodos de muestreo, examenes clínico y análisis de datos similares a los de 1965. Este informe se refiere al estudio en Neuquén. La tasa de prevalencia de bocio disminuyó desde 46,5 por ciento en 1965 a 10,7 por ciento en 1991, más alta el área rural (16,9 por ciento ) que urbana (9,8 por ciento ), con la forma difusa más frecuente que la nodular en 1965 (4,9 por ciento ) que en 1991 (1,7 por ciento ). También se halló más prevalencia en quienes consumían sal no enriquecida de salina (26,4 por ciento ) que en quienes consumían sal con iodo (10,3 por ciento ). Todas las diferencias fueron estadísticamente significativas con p<0,05. La persistencia de bocio aún en áreas urbanas y en quienes cosumen sal yodada hace pensar en la posible influencia de factores bocígenos en el suelo, agua y alimentos locales, tema que merece nuevos estudios.