1. Endemic goiter TASHKENT MEDICAL ACADEMY
Lecture for students 4 course on the topic:
Endemic goiter
Done by: assoc. prof. Muhtarova M. Z.

2. Map prevalence of iodine deficiency disorders in the world
Severe iodine deficiency (goiter> 30%)
Mild iodine deficiency (goiter 5-19,9%)
Moderate iodine deficiency (goiter 20-29,9%)
No iodine deficiency (goiter <5%)

3. Iodine deficiency disorders (IDD)
According to WHO, IDD are the most common non-communicable diseases of man
Iodine deficiency - the most common cause of mental retardation, which can be prevented

4. The risk of insufficient consumption of iodine is present at the world at:
1.5 billion people,
655 million people in the world have an endemic goiter,
43 million people have mental retardation of various degrees
30 million people have cretinism due to iodine deficiency
(WHO, 1994).

5. In all territory of the CIS iodic deficiency is defined
Why?
In the fertile soil and vegetation almost no iodine
The vegetative and animal food contains not enough iodine
Limited consumption of fish and seafood
Lack of mass iodine prophylaxis through salt iodization

6. The main problems related to iodine deficiency in the CIS
High prevalence of endemic goiter:
-from 15% to 40% in some regions;
-in mountain areas frequency of goiter rate can vary from 25-40% to 80%-64.
The lack of objective information on the problem of iodine deficiency among the population

7. Regulation of the function of the thyroid gland
T3,T4
FT3, FT4
ТТГ
ТРГ
Hypothalamus
Pituitary Gland
Thyroid gland
T3 = Triiodothyronine
T4 = Thyroxin
Blood (transport system )
Peripheral tissues

8. Thyroid and pregnancy. Fetus
16-17 week fetal thyroid fully differentiated and starts to function actively

9. The main effects of thyroid hormones
Ensure the formation of the nervous system and the skeleton in the perinatal period,
Increases oxygen consumption in all tissues except the brain, spleen, testes,
Increases the production of heat,
Have positive chronotropic and inotropic effects on the myocardium,
Increases receptor sensitivity to catecholamines;

10. The main effects of thyroid hormones
Increase the number of catecholamine receptors in the heart muscles,
Regulates the activity of the respiratory center,
Stimulates erythropoiesis,
Speeds up the metabolism and clearance of hormones and drugs, leading to a compensatory increase in the rate of their production,
Stimulates both the formation and bone resorption.

11. Endemic goiter Iodine deficiency,
Iodine deficiency develops as a result of those living in iodine-deficient regions,
Endemicity is an area, if the prevalence of thyroid enlargement even 1 degree is 5% or more in children and adolescents, or 30% or more of adults living in the area.

12. Goiter development is contributed by
Insufficient exposure:
protein;
- vitamin A;
- bromine;
- zinc;
- Cobalt;
- copper;
- Chromium.

13. Goiter development is contributed by
Excessive intake of:
Calcium
- Fluoride
- Chromium
- Manganese

14. Goiter development is contributed by
Strumogen substances contained in plants:
Turnip;
- Radishes;
- Radish;
- Peanuts;
- Carrots;
- Soy;
- Beans;
- Cauliflower;
- Peaches;
- Mango.

15. Goiter development is contributed by
Poor social and living and sanitary conditions:
In the water there are products of protein breakdown (thiourea, thiouracil, urochrome) helminthic and
bacterial contamination of the environment.

16. The severity of iodine deficiency
Mild form - goiter occurs from 10 to 30% of the population, the average urinary iodine excretion is mg / l. Hypothyroidism and cretinism are missing.
Medium form - the frequency of goiter and 50%, the level of urinary iodine excretion is reduced to 20-49% mg / l. There may be cases of hypothyroidism.
Severe form - the frequency of goiter can reach almost 100% of the average level of urinary iodine excretion less than 20 mg / l. Cretinism occurs with a frequency of 1 to 10%.

17. Mechanisms of adaptation to deficiency of iodine
In response to iodine deficiency and reduced levels of thyroid hormone increases the level of TSH, which leads to increased capture of iodine and thyroid hormone synthesis, followed by hyperplasia or hypertrophy of parenchymal cells,
Increased synthesis and metabolism of thyroid hormones in response to an increase in TSH enhances the process of circulation of iodine, that allows the body to do smaller amounts of iodine;

18. Mechanisms of adaptation to deficiency of iodine
Changes the character of the synthesis of thyroid hormones, thyroid gland begins to produce triiodothyronine, which consumes less synthesis of iodine;
Accelerating transformation into liver thyroxine in a more biologically active hormone triiodothyronine.

19. Inspection of patients with diseases of a thyroid gland
Studying of the anamnesis.
Palpation of the thyroid gland.
Ultrasound examination.
Hormone research.
Scintigraphy.
Puncture biopsy.

20. Palpation of the thyroid gland
The upper pole
The lower pole

21. Classification of endemic goiter (Nikolayev O. V., 1955)
0 degree - Thyroid not palpable;
1 degree - an enlarged thyroid gland is well detectable, especially the isthmus,
2 degree - an enlarged thyroid gland is clearly determined not only feeling, but also clearly visible when viewed during swallowing, and
3 degree - an enlarged thyroid gland with the formation of a 'thick neck',
4 degree - Form the neck dramatically changed, clearly visible goiter,
5 degree - goiter reaches a very large size;

22. Classification of goiter (WHO, 1994)
0 degree – no goiter;
1 degree - greater than the size of the share of the distal phalanx of the thumb. Goiter palpable, but not visible;
2 degree - goiter palpable and visible to the eye;

23. Classification by structural changes
Diffuse goiter;
Nodular goiter;
Mixed goiter.
Classification by functional changes:
Euthyroid goiter,
hypothyroid goiter;
hyperthyroid goiter.

24. Ultrasound examination of the thyroid gland
Ultrasonic 'slice' of the thyroid gland and surrounding structures
The surface of the skin
Thyroid lobe
Blood vessel
Trachea

25. Basic laboratory indicators
norm
TSH
0, MU/l
General Т4
5,5-1mkg/DL
nmol/l
FreeТ4
0,8-1,8 ng/DL
10-23 pmol/l
General Т3
0,9-1,8 ng/ml
1,4-2,8 nmol/l
Free Т3
3,5-8,0 ng/l
5,4-12,3 pmol/l

26. Normal volume of thyroid (ml)
Thyroid volume
For calculation of the volume of the thyroid gland add two volumes of shares, the size of the neck is neglected.
Ml volume fraction = [(SHP x DP x TA) (SL x L x TL)] x 0,479
Patients
Normal volume of thyroid (ml)
Children 6-10 years
<8
Children11-14 years
<10
15-18 years
<15
Women
<18
Men
<25

27. How does the goiter develop?
Deficiency of iodine + hereditary predisposition
the Increase of a thyroid gland
the Normal size:
Men – up to 25 ml, Women up to 18 ml

28. Iodine deficiency goiter
When iodine deficiency is a compensatory enlargement of the thyroid gland - formed goiter Long-lived iodine deficiency leads to the formation of thyroid nodules In some individuals formed the functional autonomy of the thyroid gland, most often seen in multinodular toxic goiter

29. women of childbearing age, pregnant and nursing women,
Special risk group for the most threatened in the medico-social consequences of goiter
Teenage girls,
women of childbearing age,
pregnant and nursing women,
children and adolescents

30. Consequences of chronic iodic deficiency
Pregnancy and breast-feeding thyroid dysfunction in women, violations of intellectual and physical development
children's age learning disabilities, developmental disorders, euthyroid goiter
Adults memory loss, infertility, fatigue, thyroid
Mature multinodular toxic goiter

31. Disease (condition) associated with endemic goiter
A reduction of intellectual capacity of a population
infertility, inability pregnancy, high perinatal and infant mortality - demographic problems
worsening the health of the people : a high level of morbidity, high level chronic diseases, increase in cardiovascular diseases

32. A simple solution to a complex problem
Restores iodine deficiency: mass iodine prophylaxis (iodized salt); Group iodine prophylaxis (iodide 100, Iodide 200); Individual iodine prophylaxis (iodide 100, Iodide 200).

33. Contraindications to iodine preparations
Thyrotoxicosis of any etiology
Nodular goiter with increased accumulation of radioactive isotope (hot site) or decrease in basal TSH concentrations less than 0.5 Miu/l.

34. goiter prevalence <5% (the proportion of pupils who have goiter)
Criteria for elimination of iodine deficiency diseases, proposed by WHO, UNICEF and ICCIDD (1999)
Iodization of salt> 90% (the proportion of households consume iodized salt)
goiter prevalence <5% (the proportion of pupils who have goiter)
urinary iodine of mg / l (reflects real iodine in the body)

35. Methods of iodic preventive maintenance
The mass – introduction of salts of potassium (iodide or potassium iodated) in the most widespread food:
In bread;
In water;
In salt, at:
- easy iodic insufficiency of mg/kg;
- average weight mg/kg;
- at the heavy – from 45 to 60 mg/kg.

36. Methods of iodic prevention
The group – purpose of the preparations containing iodine to groups of the population with the greatest risk of development of iodic deficiency diseases.
At easy or moderate deficiency of iodine daily additional amount of iodine is appointed:
- children of dopubertatny age mkg;
- teenagers – mkg;
- pregnant and feeding – mkg.

37. Methods of iodic prevention
The individual – prescribe transferred a strumectomy, to immigrants, and persons with existence of goitrogenic factors in a life or production.
Prescribe an antistrumin or iodide a potassium in a dose not less than mgk per day.

38. Methods of iodic prevention
At group and individual it is possible to apply lipodol – the iodated oil in capsules to intake or in ampoules for in/m introductions. 1 ml of a capsule contains 0,3 g of an iodine 1-2 times a year are accepted. At in/m preparation introduction – the effect proceeds within 2-3 years.
Action duration lidopidol it is bound to that the iodated fatty acids of a preparation are used for synthesis of a fatty tissue and the iodine slowly arrives in a blood channel in process of a fat metabolism.