High default rate in thyroid cancer management in Ibadan, Nigeria: a need for health insurance.

BACKGROUND: Differentiated thyroid cancer is a potentially curable disease provided there is early diagnosis and full compliance with management modalities. This however becomes a problem in a resource poor environment where most patients pay out of pocket resulting in poor compliance and inability to access standard care due to poverty. This retrospective study was carried out to evaluate the percentage of patients that could afford the cost of care in a premier nuclear medicine facility of a tertiary centre. PATIENTS, MATERIAL AND METHOD: A total 56 patients with differentiated thyroid cancer managed since the inception of the Nuclear Medicine Department, University College Hospital from June 2006 to March 2010 were included in the study. Socioeconomic status of the patients and the affordability of the nuclear medicine procedure for differentiated thyroid cancer post thyroidectomy were evaluated. RESULT: A total of 20 out of 56 (35.7%) patients had total thyroidectomy at presentation, while, 36 had subtotal thyroidectomy. The commonest type of thyroid malignancy was papillary thyroid cancer (51.8%), while follicular cancer accounted for 41.1%. Medullary and Anaplastic thyroid cancers were the least common. Majority of the patients evaluated were within the income bracket of 10,000-30,000 naira ($67- $200) per month). The average cost of management of thyroid cancer post total thyroidectomy was $2500 (N375 000.00) at this centre. Twenty one out of 56 patients (37.5%) could afford the $300 cost of diagnostic whole body iodine scan while only 16 patients out 21 (28.6%) could afford the ($1200) cost of radioactive iodine treatment. CONCLUSION: With average cost of management of management of thyroid cancer beyond the yearly income of majority of the patients studied, there is need for a comprehensive health insurance policy to make accessibility of care of this potentially curable disease available to most Nigerians.

Radioactive iodine ablation therapy: a viable option in the management of Graves' disease in Nigeria.

BACKGROUND: Graves' disease is an autoimmune disorder characterized by hyperthyroidism and associated features. Management of this disease condition for many decades has been largely by surgical and medical intervention. Usage of anti thyroid medication ameliorates the symptoms and effects of excessive production of thyroid hormones. Recently in Nigeria, Nuclear medicine facility became available with the option radioiodine ablative therapy for the management of Graves disease. This study highlights the benefits of radioiodine therapy against the background of equally viable medical and surgical practice. PATIENTS MATERIAL AND METHOD: All the 36 patients seen from the inception of Nuclear Medicine facility at the University College Hospital from June 2006 to May 2010 were included in this study. Sources of referral were compiled. All the patients were on anti thyroid medication at presentation. Thyroid scan was performed by Siemens E- cam gamma camera 20 minutes after intravenous injection of 3-5 mCi of Tc-99m-Pertechnetate. The patients with "diffuse toxic goiter" on thyroid scan were given 10 mCi of Iodine-131 orally and discharged home with radiosafety precautions. Most of the patients were treated 5 days post discontinuation of antithyroid medication. The patients were followed-up monthly with thyroid function tests to determine commencement of replacement therapy. RESULT: Peak incidence of Graves' disease was at 6th decade (38.9%) of all patients studied. This disease was commoner in women with a ratio of 8 to 1. Ten (27.8%) patients became hypothyroid at the 3rd month post radioactive iodine-131 treatment, while the remaining 20 (55.6%) patients became hypothyroid at the 5th month. Six patients were lost to follow up. There was no recurrence of hyperthyroidism in all patients treated. Twenty eight (93.3%) patients were maintained on 100 mcg of levo-thyroxine daily, while 2 (6.7%) patients had more than 100 mcg of levo- thyroxine daily as maintenance dose. CONCLUSION: Radioactive iodine therapy presents a safe and effective alternative to the older conventional mode of management of Graves' disease

Serum zinc, copper and magnesium in sickle cell disease at Ibadan, south western Nigeria.

Serum zinc, copper and magnesium were studied in patients with sickle cell disease in the steady state. There was significantly lower serum zinc concentration (P < 0.01) and significantly higher serum copper and magnesium in haemoglobin S patients compared with controls (HbA). In haemoglobin SC patients, there was a significant reduction in serum zinc (P < 0.01) but no significant difference in serum copper and magnesium concentrations compared with the controls. There was no significant difference in serum zinc concentration between the HbS and HbS + C patients. However there were significantly higher serum copper and magnesium in HbS than HbS + C patients (P < 0.01) The level of serum zinc has no correlation with the steady state Haematocrit or severity index score in HbS and HbS + C patients.

Plasma electrolytes, total cholesterol, liver enzymes, and selected antioxidant status in protein energy malnutrition.

Golden and Ramdath proposed the free radical theory of kwashiorkor, suggesting that the changes seen in kwashiorkor may be the result of an imbalance between the production and safe disposal of free radicals. In malnourished children, mineral metabolism and antioxidant status need renewed attention especially in relation to cause and functional significance of the changes in concentration of these substances. In the present study, the modified Wellcome classification was used to classify the protein energy malnourished children into kwashiorkor marasmic-kwashiorkor, marasmus and underweight. Twenty-six healthy and normal children were used as controls. Standard procedures were used for the analyses of the biochemical parameters. Our results showed that plasma total cholesterol, sodium, potassium and bicarbonate, beta-carotene, retinol and uric acid were significantly lower in the malnourished group than the control group (P < 0.05), while transaminases were significantly increased in the malnourished group (P < 0.05). These findings suggest an altered electrolyte and antioxidant status in protein energy malnutrition.

Serum unsaturated vitamin B12 proteins in adult patients with sickle cell anaemia (HbSS).

The unsaturated vitamin B12 binding capacity (UBBC) of serum, the three transcobalamins (TC I, TC II, TC III) and serum cobalamin have been studied in adult sickle cell patients with Hb SS. An increase in the level of the binding capacities of TC I and TC III resulting in an increase in UBBC was observed in these patients. There was no difference in the level of the binding capacity of TC II, while there was a significant reduction in the level of serum cobalamin. These changes in the pattern of these binding proteins are discussed in relation to the changes of these binding proteins in paediatric sickle cell patients with Hb SS. The results indicate that the pattern of these binding proteins changes with age among sickle cell patients resulting in an increased level of the binding capacities of TC I and TC III. These increases lend support to the view that these two similar binding proteins are involved in the defence mechanism of the body.

Need for re-evaluation of serum albumin in an African population.

Serum albumin and total proteins of healthy Nigerian adolescents aged 12-17 years were estimated. The average serum albumin value was significantly higher than previously reported twenty years ago. This increase has shown that the serum albumin concentration of Africans can be as high as that of Europeans. The results are discussed in the light of the improved standard of living and better dietary habits and indicate the necessity for re-evaluating serum albumin values in populations where the standard of living has improved over the years, since this parameter is of great diagnostic value in medical practice.

Plasma cortisol in sickle cell disease.

The plasma cortisol levels of 108 children aged 1-16 years with various Hb genotypes (AA, AS and SS) were measured. The mean plasma cortisol levels of both the AS and SS groups (during steady state) fell within the normal range but the mean of the SS group is significantly lower than the AA group. In fact, 9 of the sickle cell children had plasma cortisol levels below the normal range while no child in the HbAS and HbAA groups had plasma cortisol below the normal range. These results indicate that in sickle cell disease, there is low cortisol production while the secretion is increased during painful crisis.

Correlation between serum enzymes and serum unsaturated vitamin B12 binding proteins in primary liver carcinoma.

The serum unsaturated vitamin B12-binding capacity (UBBC), unsaturated transcobalamin (UTC) I, UTC II, UTC III levels, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase activities and bilirubin concentration were estimated in 61 patients with liver diseases (31 with hepatoma, 30 with viral hepatitis). The levels of serum cobalamin, UTC I, UTC III, UBBC, alanine and aspartate aminotransferases, and bilirubin were raised in both hepatoma and viral hepatitis patients. Serum UTC II was reduced in both conditions. Alkaline phosphatase activity was significantly increased in hepatoma. Four significant correlations were observed among these parameters in the hepatoma patients while only one significant correlation was observed in viral hepatitis.

Reference values for serum folate, erythrocyte folate and serum cobalamin in Nigerian adolescents.

Concentrations of serum folate, red cell folate and serum cobalamin were studied among 240 normal healthy Nigerian adolescents aged 12-17 years. Serum folate level was generally low with a mean of 2.8 nmol/l while red cell folate level was not low with a mean of 369 nmol/l. Mean serum cobalamin was 615 pmol/l. A negative significant correlation was observed between serum folate and red cell folate among the adolescents (r = 0.24). Another significant correlation was observed among the 14 year olds between red cell folate and serum cobalamin (r = 0.404). The folate parameters were significantly lower in the adolescents with HbAS genotype with mean serum folate of 2.2 nmol/l and red cell folate of 326 nmol/l but these differences were more marked among the girls. All the girls in the study had significantly higher serum cobalamin than the boys (p less than 0.001) but the advantage of this is not clear. These results suggest that serum cobalamin may be under some hormonal influences and the high values indicate that cobalamin may be involved in other metabolic functions from the puberty period.

Endocrine function and haemoglobinopathies: biochemical assessment of thyroid function in children with sickle-cell disease.

Thyroid function was assessed in ninety children with homozygous sickle-cell disease (haemoglobin genotype SS) in forty-five children with heterozygous sickle-cell trait (AS) and in 162 control children with haemoglobin genotype AA. Serum levels of thyroxine, the in vitro triiodothyronine resin uptake and the calculated index of 'free thyroxine' were not significantly different in the three groups. The distribution of individual thyrotropin (TSH) values showed that only 11% of the HbSS subjects had values below the 95% confidence limits for the HbAA controls. However, the mean level of TSH was significantly lower in the HbSS than the other two groups of children.

Cerebrospinal fluid folate and cobalamin levels in febrile convulsion.

Folate and cobalamin parameters were studied in the serum and cerebrospinal fluid of 40 febrile paediatric patients. Eighteen of these children were in a state of febrile convulsion while the remaining 22 were non-convulsing. The serum folate concentration of all the patients was higher than that of the control group but the highest value was found in the convulsing children. There was no significant difference in the CSF folate levels between the two groups of patients. The serum cobalamin levels of the patients were significantly lower than those of the control children and the lowest mean was observed in the convulsing state. On the other hand, there was no difference in the CSF cobalamin between the convulsing and non-convulsing children. These results confirm that there is an effective blood-brain barrier system for folate even when serum folate levels are higher than normal. There is also a definite decrease in serum cobalamin during pyrexia but this decrease is more apparent in the convulsing state. The role of cobalamin metabolism in convulsion is not clear.

Serum aminotransferase activities in sickle cell children during crises.

A total of 78 children with diagnosis of sickle cell disease (HbSS) aged 1-12 years were involved in this study; while 60 normal children (HbAA) of the same age range served as controls. Serum levels of alanine aminotransferase (EC 2.6.1.2), aspartate aminotransferase (EC 2.6.1.1), total protein and albumin were assayed in all the sickle cell children both in crises and steady state and in all the normal children. During crises, most of the sickle cell children had significantly raised levels of serum aminotransferases together with reduced levels of serum total protein and albumin. When these levels are compared with the ones observed during the steady state, the differences are highly significant. On the other hand, when the results obtained during the steady state are compared with those of the control group, the differences are not significant. These results are discussed in relation to the hepatic degenerative changes observed in sickle cell crises. It is clear from this study that the more clinical painful crises the children experience, the hepatic cells would be exposed to persistent injury which may eventually result in cell death.

Serum cobalamin concentration in sickle cell disease (HbSS).

The serum cobalamin, serum folate, erythrocyte folate concentrations and total leucocyte and neutrophil counts have been studied in sickle cell children (with HbSS) during the steady state. There was a significant reduction in serum cobalamin concentration with significant increases in both the total leucocyte count and neutrophil differential. A relationship was also observed between the serum cobalamin and erythrocyte folate. The lowest erythrocyte folate levels were observed in patients with the lowest serum cobalamin concentration. These abnormalities are discussed in relation to the possible role of cobalamin in the synthesis of erythrocyte folate polyglutamate and possible immunological role of cobalamin among these children. These results lend support to the view that daily cobalamin supplementation along with folate (which is being given) may prove beneficial to the sickle cell patients as it may lower the frequency and severity of infections.

Comparison of folate levels in convulsing and non-convulsing febrile children.

The relationship between folic acid levels and occurrence of convulsion in febrile subjects was studied in thirty-two children aged 8 months to 5 years. Both the serum and red cell folate levels were significantly higher in the febrile children who convulsed than in those who did not convulse. When the period of convulsion was more than thirty minutes, there was a significant rise in the red cell folate. These results suggest that the accumulation of folate in the serum and red cell may be causally related to the development of the convulsing state in febrile children.

Abnormalities of serum transcobalamins in sickle cell disease (HbSS) in Black Africa.

The unsaturated vitamin B12 binding capacity (UBBC) of serum, the three transcobalamins (TC I, TC II, TC III), and the total leucocyte and neutrophil counts have been studied in paediatric patients with sickle cell disease (SCD). Increase in the level of the binding capacities of TC I and TC II with concomitant increase of UBBC was observed in these children who also had increased total white blood and neutrophil counts. There was a significant reduction in the level of endogenous B12. These abnormalities are discussed in relation to the deficiency of the splenic reticuloendothelial function, immunologic defect, hepatic degenerative changes and aplastic crisis observed in SCD. These results lend support to the view that transcobalamins are involved in the defence mechanism of the body. The significant reduction in serum cobalamin in SCD suggests a higher demand on this vitamin for metabolic functions, especially for the sparing of folate.

Serum aspartate and alanine aminotransferase activities in protein energy malnutrition.

The activities of serum aspartate and alanine aminotransferases were measured in protein energy malnutrition (PEM). These enzyme activities were both increased in PEM and fell as recovery was established. There was a marked reduction in the serum albumin level, and an inverse relationship was observed between the serum albumin levels and the enzyme activities. The relationship is discussed in the light of the hepatocellular damage of PEM. The assay of these enzyme activities along with estimation of serum albumin in PEM will prove very useful in the diagnosis of the liver damage that may occur in PEM before clinical manifestations are established.

Serum transcobalamins in healthy Nigerian children.

The unsaturated vitamin B12-binding capacity (UB12BC) and the three transcobalamins (TC I, TC II, TC III) have been studied in the serum of normal healthy Nigerian children. The serum UB12BC level was very high in the children: TC I accounted for 39.5% of UB12BC, TC II accounted for 49.5% and TC III accounted for 11%. The results are discussed in the light of the variations in the distribution of transcobalamins in children from what has been previously reported among the African adults. The high percentage of TC I in the children is discussed in the light of a possible immunological role of this transcobalamin. There was an inverse relationship between TC I and TC II levels. A sex difference in UB12BC and TC I levels was observed. The girls had higher UB12BC and this was due to higher TC I, but the advantage of this is not clear.

Increase of body temperature and folic acid metabolism.

Folic acid metabolism was studied in forty-four febrile children aged 2 months -9 years by measuring their serum and red cell folate levels. In all the children, there was a significant reduction in red cell folate along with a steady rise in serum folate as the body temperature increased above 39 degrees C. There was no correlation between the folate parameters and the pathological cause of the pyrexia (malaria or broncho-pneumonia). These results suggest that a rise in body temperature causes a breakdown of folate stores, which leads to some disturbance of folate metabolism. The extent of this disturbance is not known but it may have some detrimental effects on growing children.

The usefulness of radioisotopic dilution assay in a population with high serum vitamin B12 concentration.

This report describes the results of a vitamin B12 study among ninety normal healthy school children using commercial radioisotopic dilution assay kits. Values obtained in this study are higher than those obtained in previous study by the microbiological assay using L. leichmannii as the test organism. These high values render the commercial kit unsuitable in its present form in the diagnostic process of liver and related diseases where serum vitamin B12 are significantly elevated. Some dilution of the serum will be essential if the commercial kits are to prove useful among populations with normal high vitamin B12 concentrations.