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.

[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.

Administrando yodo radioactivo. Piensa en las alarmas de seguridad de los aeropuertos / Giving radioiodine? Think about airport security alarms

La sensibilidad aumentada de los detectores en los aeropuertos, el aumento del número de pruebas isotópicas y la globalización de la sociedad han dado lugar a varias falsos positivos en las alarmas de radioactivos de los aeropuertos y lugares públicos. Este trabajo presenta dos nuevos casos de pacientes que alertaron las alarmas de seguridad en el aeropuerto después de haber recibido 740MBq de 131I en bocio no-tóxico. Los intentos de comparar la literatura son sorprendentemente limitados en relación a este problema. Un hombre de 57 años desencadenó una alarma en tres aeropuertos diferentes durante los días 17, 28 y 31 después de haber recibido exposición a yodo radioactivo. Curiosamente, mientras tanto, en los días 18 y 22, no se detectó la radiación en el aeropuerto, donde fue detenido dos veces más adelante como fuente de radiación. El segundo caso presenta una mujer de 45 años que activó los detectores de la alama de seguridad cuando cruzó una frontera en un viaje en autobús después de haber recibido yodo radioactivo(AU)

An increased sensitivity of airport detectors, a growing number of isotopic tests, and globalization of the society have raised a number of false positive radioactive alarms at airports and public places. This paper presents two new cases of patients who triggered airport security alarms after receiving 740MBq of 131I for non-toxic goitre and attempts to compare surprisingly limited literature concerning this problem. A 57-year-old man triggered a security alarm at three different airports on the 17th, 28th, and 31st day after radioiodine exposure. Interestingly enough, in the meantime, on the 18th and 22nd day, no radiation was detected in him at the airport where he was twice detained as a source of radiation later on. The second case presents a 45-year-old woman who activated security alarm detectors while crossing a border on her coach trip 28 days after radioiodine administration(AU)

[Peculiarities of formation, clinical presentations and therapy of diffuse nontoxic goiter of children].

The paper deals with the peculiarities of formation, clinical presentations and therapy of diffuse nontoxic goiter of children. The paper highlights the connection of the disease with the genetic predisposition, the impact of natural and anthropogenic strumagenes, immune processes. The clinical presentations of the diffuse nontoxic goiter are diffuse enlargement of thyroid gland, normal or high level of thyrotropichypophysis hormone when the content of thyroxin and triiodothyronine is normal, which is treated as the subclinic hypothyroidism syndrome. The variety of the disease pathogenesis theories leads to testing of different therapeutic methods, the principal ones among them are the use of iodine preparation and replacement therapy.

Investigar y curar: Conocimientos y profilaxis del bocio endémico de la Argentina (1916-1958) / Research and cure: Knowledge and prophylaxis of endemic goiter in Argentina (1916-1958)

El presente trabajo se orienta a reconstruir el recorrido histórico de la producción de conocimiento, así como los debates acerca de la enfermedad del bocio endémico en Argentina, fundamentalmente entre 1916 y 1955. Tomando en cuenta aspectos sociales, políticos y materiales, el trabajo explora la resignificación del conocimiento científico y médico en términos de medidas de prevención y tratamiento de la salud, a través del posicionamiento de diversos actores sociales implicados y de diversos contextos históricos e institucionales (AU)

The present paper focuses on the reconstruction of the historical circumstances of knowledge production as well as and the debates about endemic goiter disease during the period 1916-1955 in Argentina. Taking into account the social, political and material dimensions, this text explores there-signification of scientific and medical knowledge oriented to the prevention and health treatment, through the positioning of several social actors engaged all along the period, and the diverse historical and institutional contexts (AU)

[Hyperthyroidism in children. Experience in internal medicine in Mali]. / Hyperthyroïdie chez l'enfant. Expérience d'un service de médecine interne au Mali.

INTRODUCTION: Thyroid pathology is frequent in Mali, which is an endemic zone for goiter. But this pathology rarely occurs in children. The purpose of our study was to characterize this illness among children in Mali. METHODS: We report on patients aged less than 15-year old who presented with clinical signs and symptoms with hyperthyroidism at the medicine service at Hospital de Point G from January 1999 and December 2005 to determine the characteristics of hyperthyroidism. RESULTS: The frequency was 9.6 per thousand (38/3972), with an average age of 12.5+/-3.34-year. The sex ratio was 3 girls/1 boys. The most common symptoms were tachycardia (n=30, 78.9%), palpitations (n=15, 34.4%). 31 patients (81.5%) presented with exophthalmoses, 93.5% being bilateral. Weight loss was present in 31.5% (n=12). Goiter was present in 37 patients (97.4%). The goiter was diffuse in 27 patients (73%) and nodular in 10 (27.%). The presence of goiter caused signs of compression in the neck in half of the cases: dyspnea and dysphonia were the most common consequences. TSH less than 0.05 microUI/1 was used to confirm the diagnosis. Graves's disease was the most common cause (n=32, 84.2%), followed by toxic adenoma (n=4, 10.5%). Other causes included toxic multinodular goiter and thyroiditis. Etiologies were independent of sex and age: (p=0.95). All patients were started on medical therapy upon diagnosis. 7 patients (18.4%) were lost to follow-up during the 6 months of treatment. Remission was obtained in 26 patients (83.9%), and relapse occurred in 5 patients (16.1%). CONCLUSION: The frequency of hyperthyroidism in children in Mali is a problem in a goiter endemic zone like Mali. Poor general health in children and signs and symptoms of neck compression are markers of progressive disease.

[The condition and prospects of Russian endocrinology].

The article presents a brief essay dedicated to the development of endocrinology in our country since pre-war time. The article covers the most promising areas of endocrinology, from endemic goiter to the introduction of the newest technologies to endocrinology, and informs the readers about structural and organizational changes in the diabetological service, including the establishment of Institute of Diabetes and Institute of Pediatric Endocrinology, the first ones in Russia, the establishment of diabetological service, including State Registry of Diabetic Patients, a school for adult patients, etc. Another issue is the establishment of Growth Center and the introduction of genetic engineering growth hormone preparations into the practice of treatment of short children. Once again, the authors emphasize the issue of fighting endemic goiter. Many tasks of Russian endocrinology are now considered weighty matters of state.

Bócio endêmico em Minas Gerais: a pesquisa biomédica da terra dos "papudos"

Mostra como os dois elementos - barbeiros e eugenia - foram argumentos usados para justificar pesquisas sobre o bócio endêmico em Minas Gerais, no início do século XX.(AU)

Evaluation of the impact of an iodine supplementation programme on severely iodine-deficient schoolchildren with hypothyroidism.

BACKGROUND: Northern rural areas of Tehran have been shown to have severe iodine deficiency in our previous studies. In 1989 the inhabitants of these villages received an injection of iodised oil, followed by iodised salt distribution in 1993. The aim of the present study was to evaluate the effect of the iodine supplementation on iodine-deficient schoolchildren with hypothyroidism in these villages. METHODS: In total, 571 students aged 6-14 years were studied. Goitre was graded according to the World Health Organization classification. Serum concentrations of thyroid hormones (thyroxine (T4) and triiodothyronine (T3)) and thyroid-stimulating hormone (TSH) were determined using commercial kits, and urinary iodine was measured using a digestion method. The results were compared with data from our previous study in 1989. RESULTS: Total goitre rate decreased by 42% in 1999 compared with that in 1989. A significant decrease in Grade 2 goitre concomitant with an increase in Grade 1 goitre was seen (P < 0.001). Values of the variables studied before (1989) and 10 years after iodine supplementation (1999) were: median urinary iodine excretion, 2.0 vs. 19.0 microg dl(-1) (P < 0.001); T4, 6.5 +/- 2.0 vs. 8.4 +/- 1.6 microg dl(-1) (P < 0.001); T3, 177 +/- 38.0 vs. 145 +/- 29.0 ng dl(-1) (P < 0.001); TSH, 10.8 +/- 15.1 vs. 1.8 +/- 0.8 microU ml(-1) (P < 0.001). No correlation was found between thyroid hormones and TSH on the one hand, and goitre and urinary iodine, on the other. Serum T4, T3 and TSH concentrations were within normal ranges in all schoolchildren in 1999. CONCLUSION: This study showed that euthyroidism induced by administration of iodised oil in iodine-deficient schoolchildren with hypothyroidism is sustained following the consumption of iodised salt.

Iodized salt consumption maintains euthyroidism in iodine-deficient hypothyroid subjects.

Following previous reports of impaired physical and intellectual growth, hearing deficit, hypothyroidism, and hyperendemic goiter in Kiga, and the administration of iodized oil injection, this study was conducted to evaluate whether or not the effect of the injection could be sustained by iodized salt supplementation. In 1989, one mL of iodized oil solution containing 480 mg of iodine was injected in 198 schoolchildren aged 8 to 14 years. Four years later, in 1993, iodized salt consumption was begun and has since been continued. Serum thyroid hormones, RT3 uptake and thyroid-stimulating hormone (TSH) were measured before, and three, four, and six years after intervention (1989, 1992, 1993, and 1995). Assessment of urinary iodine was performed by the Foss method at the same intervals mentioned above. Prior to the injection, 94% had grade 2 goiters; four years after injection, 26% and 41% had grades 2 and 1 respectively, and 30% had no goiter (p < 0.001). Two years after the introduction of iodized salt consumption, 5 and 39% had grades 2 and 1 goiter, and 56% were not goiterous. Urinary iodine was 11.4 +/- 19.8 micrograms/L before intervention, and was increased to 93 +/- 66 and 92 +/- 34 micrograms/L, three and four years, respectively, after intervention. Two years after iodized salt consumption it was 161 +/- 34 micrograms/L. Mean serum T4 was 5.0 +/- 2.0, 9.6 +/- 2.0, 9.6 +/- 2.0 and 9.2 +/- 1.5 micrograms/dL; serum TSH was 20.3 +/- 22.8, 2.1 +/- 1.9, 2.5 +/- 1.6 and 2.9 +/- 1.7 mU/L; before and three, four, and six years after the beginning of the study. All children were euthyroid after three, four, and six years of study. Findings show the benefits of iodized oil administration in decreasing goiter size and in reversing abnormal thyroid function. These effects are sustained by iodized salt consumption in schoolchildren who had been previously hypothyroid due to iodine deficiency.

Application of staging systems for differentiated thyroid carcinoma in an endemic goiter region with iodine substitution.

OBJECTIVE: To evaluate and compare staging systems for differentiated thyroid carcinoma and predicted outcome in an endemic goiter region with iodine substitution and to examine the risk profile of differentiated thyroid carcinoma and compare it against nongoiter regions. SUMMARY BACKGROUND DATA: Differentiated (papillary or follicular) thyroid carcinoma has a favorable prognostic outcome. In numerous studies prognostic factors have been identified and staging systems created, particularly in Anglo-American centers (nonendemic goiter regions), to evaluate individual prognostic outcome. METHODS: In a retrospective study, the authors assessed 440 patients with differentiated thyroid carcinoma (papillary, n = 293; follicular, n = 147) and a long-term follow-up of median 10.6 years to determine the predictive accuracy of nine staging systems applicable to the study population; the systems were compared by calculating the proportion of variation explained. RESULTS: With regard to cause-specific mortality, the difference between the respective stages and/or risk groups was highly significant for every staging system. By means of calculating the proportion of variation explained, MACIS scoring supplied the most reliable prognostic information for differentiated thyroid carcinoma (relative importance 16.93%). EORTC and UICC/AJCC systems had a relative importance of 16.34% and 13.96%, respectively, also a high level of accuracy; this implies that they are superior to the other six staging systems. If we separate papillary and follicular carcinoma, for the former the MACIS score with a relative importance of 15.05% is clearly superior to the other staging systems, whereas for the latter the EORTC score and the UICC/AJCC staging system, with relative importance of 17.04% and 16.58%, respectively, yield the best prognostic information. CONCLUSIONS: By applying staging systems in an endemic goiter region with iodine substitution, the best prognostic information for papillary thyroid carcinoma has been achieved with the MACIS score, while for follicular thyroid carcinoma the EORTC score and the UICC/AJCC system have the best prognostic accuracy. Because of the individual factors, which are easy to obtain and generally available (age, T, N, M classification), the uncomplicated handling, and the widespread use and the good predictive accuracy, the UICC/AJCC classification is the staging system of choice for comparing published results.

Prospects of fortification of salt with iron and iodine.

Fortification of salt with iron has been developed by the National Institute of Nutrition (NIN) as a strategy for the control of iron deficiency anaemia (IDA) in India, similar to iodization of salt for control of iodine deficiency disorders (IDD). Stability of the iron fortified salt (IFS), its bioavailability and organoleptic evaluation of food items containing the IFS have been demonstrated. Acceptability and effectiveness of the IFS in school children and in multicentric community trials have been demonstrated. With the introduction of universal iodization of salt as a national policy in 1988, NIN has developed a formulation for double fortification (DFS) of salt with iodine and iron. The stability of the nutrients under laboratory conditions along with their bioavailability were found to be good but varying with the quality of salt used. The DFS has been evaluated in controlled trials in tribal communities and in residential school children. The findings of these studies are discussed. Overall, in these trials, DFS effectively controlled iodine deficiency but a clear impact on reducing anaemia was not demonstrated. In residential schoolchildren, increased urinary excretion of iodine as well as reduced anaemia were observed. The quality of salt has been found to be an important determinant of the stability of iodine in DFS. Further evaluation of this potentially important intervention is in progress.

[Diagnosis and therapy of patients with euthyroid goiter]. / Diagnostiek en therapie bij patiënten met euthyreotisch struma.

Nontoxic goitre is common, even in areas where iodine intake is sufficient. The most important symptoms and signs of nontoxic goitre are caused by compression of vital structures in the neck or upper thoracic cavity. In any patient with goitre the serum concentration of thyroid-stimulating hormone (TSH) should be measured to detect or exclude clinically inapparent (subclinical) hyper- or hypothyroidism. CT and MRI are expensive but very sensitive methods to identify tracheal compression and to determine intrathoracic extension. Thyroid ultrasonography and scintigraphy are not routinely indicated. Fine-needle aspiration biopsy is indicated in patients with fast-growing nodules and nodules that have a firmer consistency than other nodules within the gland. Thyroidectomy is standard therapy for young and otherwise healthy patients, especially when prompt decompression of vital structures is required. Radioiodine therapy is an attractive alternative to surgery in older patients, in those with cardiopulmonary disease, and in those with recurrent goitre. Thyroxin therapy may be tried in young patients with small, diffuse goitres who have normal serum TSH concentrations.

[Choice of therapy in unifocal functional autonomy of the thyroid gland with hyperthyroidism]. / Zur Wahl der Therapie bei der unifokalen funktionellen Autonomie der Schilddrüse mit Hyperthyreose.

Over the last 20 years, unifocal functionally autonomous nodes (UFA) of the thyroid have accounted for more than one third of all patients with hyperthyroidism in the former iodine-deficient and goiter-endemic region of Bern. This situation calls for a special diagnostic approach, i.e. etiologic diagnosis of any solitary nodule and careful consideration of therapy in contrast to regions with iodine excess where UFA is very rare, such as the USA. Therapy is recommended even where hyperthyroidism is still latent (blocked TRH test, normal TT3 and TT4) and reliably leads to subjective and objective improvement even in oligosymptomatic individuals. The safe and easy radioiodine therapy (RIT) is preferred in elderly patients with associated conditions. Surgical resection is recommended chiefly where malignancy is suspected or RIT is technically inappropriate. Both methods produce prompt eradication of the source of hyperthyroidism. The most frequent complication is hypothyroidism requiring lifelong follow-up.

[Iodine and thyroid hormone metabolism in pregnancy]. / Jod- und Schilddrüsenhormonstoffwechsel in der Schwangerschaft.

The influence of pregnancy on thyroid function as well as important interactions of pregnancy and thyroid disorders are of high clinical importance. During the last decade knowledge of these issues greatly influenced clinical aspects and basic science. Because of the increasing frequency of thyroid disorders during pregnancy, knowledge of these issues is important in order to diagnose, treat and manage all patients exposed to these problems.

[The usefulness of thyroxine treatment after subtotal thyroidectomy for endemic goiter]. / Utilità del trattamento con tiroxina dopo tiroidectomia subtotale per gozzo endemico.

The aim of the present study was to assess the appropriateness and value of prophylactic thyroxine therapy in the treatment of postoperative complications (relapse, postoperative hypothyroidism) following subtotal thyroidectomy for endemic goiter. The study was carried out in a group of 139 patients undergoing subtotal thyroidectomy for endemic goiter between 1978 and 1987. Clinical follow-up included hematochemical and scintigraphic analyses. Patients were divided into two groups. The first group included 74 patients who received postoperative hormone replacement therapy. The second group of 65 patients did not receive any treatment. results show that hormone replacement therapy is unnecessary in most cases since the majority of patients require euthyroid values a few months after operation. Thyroxine therapy was indicated, however, in cases of clinically evident postoperative hypothyroidism which persisted during follow-up.