中国甲状腺疾病诊治指南 – 甲状腺结节

  目的  了解成人甲状腺疾病的流行状况相关影响因素。  方法  2017 — 2018年在辽宁省沿海的营口市和内陆的沈阳市分别抽取1个社区和1个行政村,共计4个社区（村）作为调查点。按年龄和性别构成在调查点整群抽取住满5年 ≥ 18岁常住人口进行问卷调查,甲状腺超声检查,检测血碘、尿碘、盐碘和甲状腺功能及抗体[促甲状腺激素（TSH）、游离三碘甲状腺原氨酸（fT₃）、游离甲状腺素（fT₄）、甲状腺过氧化物酶抗体（TPOAb）、甲状腺球蛋白抗体（TgAb）],评价碘营养及甲状腺疾病患病情况及影响因素。  结果   共调查18～85岁成人2931人,尿碘中位数为167.6 µg /L,碘营养水平总体适宜;血碘中位数为62.1 µg /L,低血碘者125例,占4.3 %,高血碘186例,占6.4 %;成人甲状腺疾病患病率37.15 %,其中甲状腺结节、自身免疫性甲状腺炎、地方性甲状腺肿（地甲肿）、甲状腺功能减退症（甲减）、亚临床甲减、甲状腺功能亢进（甲亢）和亚临床甲亢患病率分别为20.37 ％、16.17 %、1.91 ％、1.43 %、5.53 ％、0.92 %和0.61 %。甲减、甲亢、AITD、甲状腺肿和甲状腺病患病率在不同血碘组间差异有统计学意义（P < 0.05）。甲状腺疾病发病与性别（OR = 2.03）、家族史（OR = 1.65）、年龄（OR = 1.33）、超重或肥胖（OR = 1.60）、血碘、富碘食品摄入及收入等因素密切相关。  结论   辽宁地区成人甲状腺疾病患病率居于中等发病水平,性别、年龄、家族史、体质指数过高和碘营养状况与甲状腺病发病密切相关,女性及中老年人应为甲状腺疾病防治的重点人群,各地应结合人群碘营养状况,科学补碘,预防甲状腺病发生。     

Iodine deficiency disorders

Iodine deficiency disorder (IDD) affects 800 million people in the world, yet iodine supplementation is one of the most cost-effective nutritional interventions known. Iodine is incorporated into thyroid hormones, necessary for regulating metabolic rate, growth, and development of the brain and nervous system. IDD may appear as goiter in adults, usually not a serious problem, or in cretinism in children, which is marked by severe mental and physical retardation, with irreversible hearing and speech defects and either deaf-mutism, squint and paralysis, or stunting and edema. Children supplemented by age 1 or 2 can sometimes be helped. Foods contain variable amounts of iodine dependent on the soil where they are grown, hence mountainous and some inland regions have high goiter and IDD incidence. There are also goitrogenic foods, typically those of the cabbage family. Diagnosis is clinical or by blood tests for thyroid hormone levels and ratios. Finger-stick methods are available. Prevention of IDD is simple with either iodized salt or flour, iodinated central water supplies, injectable or oral iodine-containing oil. All cost about $.04 per person per year, except injections, which cost about $1 per person, but have the advantage that they could be combined with immunizations. Local problems with supplements are loss of iodine in salt with storage in tropics, and local production of cheaper uniodinated salt. Emphasis should be given to pregnant women and young children. There is no harm in giving pregnant women iodine injections in 2nd or 3rd trimester.     

Iodine deficiency in pregnancy: the effect on neurodevelopment in the child

Iodine is an integral part of the thyroid hormones, thyroxine (T(4)) and tri-iodothyronine (T(3)), necessary for normal growth and development. An adequate supply of cerebral T(3), generated in the fetal brain from maternal free T(4) (fT(4)), is needed by the fetus for thyroid hormone dependent neurodevelopment, which begins in the second half of the first trimester of pregnancy. Around the beginning of the second trimester the fetal thyroid also begins to produce hormones but the reserves of the fetal gland are low, thus maternal thyroid hormones contribute to total fetal thyroid hormone concentrations until birth. In order for pregnant women to produce enough thyroid hormones to meet both her own and her baby's requirements, a 50% increase in iodine intake is recommended. A lack of iodine in the diet may result in the mother becoming iodine deficient, and subsequently the fetus. In iodine deficiency, hypothyroxinemia (i.e., low maternal fT(4)) results in damage to the developing brain, which is further aggravated by hypothyroidism in the fetus. The most serious consequence of iodine deficiency is cretinism, characterised by profound mental retardation. There is unequivocal evidence that severe iodine deficiency in pregnancy impairs brain development in the child. However, only two intervention trials have assessed neurodevelopment in children of moderately iodine deficient mothers finding improved neurodevelopment in children of mothers supplemented earlier rather than later in pregnancy; both studies were not randomised and were uncontrolled. Thus, there is a need for well-designed trials to determine the effect of iodine supplementation in moderate to mildly iodine deficient pregnant women on neurodevelopment in the child.     

Iodine deficiency and neonatal hypothyroidism

The incidence of neonatal hypothyroidism, as reflected in cord-blood thyroxine and thyrotropin levels, varied from 0.6% to 13.3% in iodine-deficient and normal regions of India (selected districts of Uttar Pradesh and Kerala and the city of Delhi), depending on the degree of environmental iodine deficiency. In populations with a high incidence of neonatal hypothyroidism, an increased prevalence of nerve deafness and a shift to the left in the distribution of IQ scores (towards lower scores) have been demonstrated. These indications of mild brain damage suggest that nutritional iodine deficiency can present in other ways than goitre or cretinism. Determination of the incidence of neonatal hypothyroidism using dried cord-blood spot screening appears to be the most useful and reliable method to assess the risk of brain damage in iodine-deficient areas.     

Iodine deficiency disorders in Europe

Recent data on iodine excretion in the urine of adults, adolescents and newborns and on the iodine content of breast milk indicate a high prevalence of iodine deficiency (moderate in many cases and severe in a few) in many European countries. These cases may manifest as subclinical hypothyroidism in neonates and as goitre in adolescents and adults. Lack of iodine causes not only goitre, but also mental deficiency, hearing loss and other neurological impairments, and short stature due to thyroid insufficiency during fetal development and childhood. Although iodinated salt is available theoretically in most countries where it is needed, its quality and share of the market are often unsatisfactory. In many countries where only household salt is iodinated the iodine content has been set too low owing to an overestimation of household salt consumption. Governments are therefore urged to pass legislation and provide means for efficient iodination of salt wherever this is necessary.     

Iodine deficiency: current situation and future prospects

Iodine deficiency disorders (IDD) is a major public health problem worldwide. WHO estimates that 740 million people are currently affected by goitre. The consequences of iodine deficiency on health are the results of hypothyroidism and the main one is impaired development of foetal brain. IDD is the first cause of preventable brain damage in children. The recommended strategy to correct IDD rests upon salt iodisation. Over the last 20 years, the international community mobilised to eliminate IDD under the leadership of WHO, Unicef and ICCIDD. It resulted in remarkable progress in IDD control, especially in Africa and in South East Asia where the endemic is the most severe. It is estimated that 68% of the populations of affected countries have currently access to iodised salt. However, out of the 130 affected countries, about 30 have no programme. Besides, salt quality control and monitoring of population iodine status are still weak in many countries, thus exposing the population to an excessive iodine intake and subsequently to the risk of iodine-induced hyperthyroidism. In addition, IDD is re-emerging in some countries, especially in Eastern Europe after it had disappeared. In order to reach the goal of IDD elimination, it is important to insist on the sustainability of salt iodisation programmes, which implies an increased commitment of both health authorities and representatives of the salt industry.     

碘缺乏病知晓率调查与分析

目的弄清博爱县碘缺乏病防治知识知晓率,为该病的健康教育提供参考依据。方法对随机抽出该病目标人群,进行问卷调查,然后进行统计学分析处理。结果博爱县碘缺乏病防治知识知晓率为:在地方病健康教育项目实施前75.93%,项目实施后为90.93%(χ2=4.34,P0.05)。结论博爱县碘缺乏病防治知识知晓率已达到国家要求(中部农村居民70%,农村小学生80%),应当巩固。     

Iodine deficiency and iodine prophylaxis experience in Sicily

Twenty years ago we described an area of goiter endemia in North-Eastern Sicily. In this area endemic goiter was associated to a variable degree of iodine deficiency and, in some places, also to an increased thiocyanate urine excretion. Our studies have demonstrated a strict relationship between iodine deficiency and congenital hypothyroidism (both permanent and transient), an increased prevalence of autonomously functioning thyroid nodules and an increased prevalence of thyroid cancer (follicular and anaplastic histotypes). A number of cases of endemic cretinism have also been described. An active iodine prophylaxis program has been carried in the town of Troina in the years 1979-87, by iodinating the municipal water supply. This intervention caused the disappearance of goiter in schoolchildren in only five years. In the last 20 years the prevalence of goiter has decreased in all endemic areas probably because of the "silent prophylaxis", due to improved socio-economic conditions and industrial food consumption. Today the persistence of endemic goiter confirms the inadequacy of the silent iodine prophylaxis and the need to immediately introduce an active iodine prophylaxis in Sicily.     

1998～2006年安陆市碘缺乏病监测结果分析

为了评价安陆市食盐加碘以来,防治碘缺乏病(IDD)效果及存在问题,进一步制定和完善碘缺乏病防治策略,1998～2006年的9年时间里,安陆市根据全国加强碘缺乏病控制的要求,对全市15个乡(镇)进行了碘缺乏病监测,现将     

Iodine and selenium deficiency associated with cretinism in northern Zaire

Selenium status was determined in an endemic-goiter area and in a control area of Zaire. Compared with the reference values of a noniodine-deficient area, serum selenium in subjects living in the core of the northern Zaire endemic-goiter belt (Karawa villages) was seven times lower in 52 school-children and similarly low in 23 cretins; erythrocyte glutathione peroxidase (RBC-GPX) was five times lower in schoolchildren and still two times lower in cretins (P = 0.004). In a less severely iodine-deficient city of the same endemia (Businga), selenium status was moderately altered. RBC-GPX activity was linearly associated with serum selenium concentration up to a value of 1140 nmol/L and leveled off at approximately 15 U/g Hb at greater selenium concentration. At Karawa villages, selenium supplementation normalized both the serum selenium and the RBC-GPX. This combined iodine and selenium deficiency could be associated with the elevated frequency of endemic myxedematous cretinism in Central Africa.     

Iodine deficiency mitigates growth retardation and osteopenia in selenium-deficient rats

Selenium deficiency is associated with impaired bone metabolism and osteopenia in rats. However, it is not known how combined selenium and iodine deficiency affects bone metabolism. Therefore, we investigated the effect of selenium and iodine deficiency on bone metabolism in 2nd-generation selenium- and iodine-deficient rats. Selenium-deficient (Se-), iodine-deficient (I-), selenium- and iodine-deficient (Se-/I-), and control rats (Se+/I+), were pair-fed their respective diets until they were 74 d old. Each pair-fed rat was fed a selenium-adequate diet in the same amount as that consumed the day before by its selenium-deficient counterpart, taking food spillage into account. The skeletal phenotype was analyzed by dual energy X-ray absorptiometry, histomorphometry, and bone metabolism markers. Erythrocyte glutathione peroxidase activity (Gpx) and plasma thyroid hormones were measured to assess selenium and iodine status, respectively. In both Se-/I+ and Se-/I- rats, Gpx was reduced by 99% compared with pair-fed Se+/I+ and Se+/I- rats (P < 0.001). Iodine deficiency reduced plasma thyroxine by 64% in the 2 iodine-deficient groups (P < 0.001). Body weight, tail length, plasma insulin-like growth factor, pituitary growth hormone concentration, and femur and tibia bone mineral density were significantly greater in the Se-/I- rats than in the Se-/I+ rats. This study shows that iodine deficiency mitigated growth retardation and osteopenia in 2nd-generation selenium-deficient rats and suggests that adequate selenium status should be ensured before measures are taken to correct iodine deficiency.     

评估碘缺乏病流行状况的指标

1999年 5月 ,ＷＨＯ、国际控制碘缺乏病理事会 (ＩＣＣＩＤＤ )和联合国儿童基金会 (ＵＮＩＣＥＦ)联合在日内瓦召开技术咨询会议 ,对碘缺乏病状况及其消除的评估指标进行更新、修订。本文对这次会议评价碘缺乏病进展的最常用指标摘录如下。1　消除碘缺乏病的进程指标1.1　影响碘盐浓度的因素　影响消费者从碘盐中摄取碘的因素 :①不同浓度的加碘量 ;②在食盐生产和分装环节上加碘浓度不均匀 ;③碘盐的包装质量、贮存和运输条件 ;⑤碘盐生产、清洗及家庭烹调食物中碘的丢失。资料表明 ,从生产到用户环节盐碘损失量为 2 0 % ,烹调过程损失 2 …