Local versus WHO/International Council for Control of Iodine Deficiency Disorders-recommended thyroid volume reference in the assessment of iodine deficiency disorders.

OBJECTIVE: Iodine deficiency endemia is defined by the goitre prevalence and the median urinary iodine concentration in a population. Lack of local thyroid volume reference data may bring many health workers to use the European-based WHO/International Council for Control of Iodine Deficiency Disorders (ICCIDD)-recommended reference for the assessment of goitre prevalence in children in different developing countries. The present study was conducted in non-iodine-deficient areas in Malaysia to obtain local children's normative thyroid volume reference data, and to compare their usefulness with those of the WHO/ICCIDD-recommended reference for the assessment of iodine-deficiency disorders (IDD) in Malaysia. DESIGN AND METHODS: Cross-sectional thyroid ultrasonographic data of 7410 school children (4004 boys, 3406 girls), aged 7-10 years, from non-iodine-deficient areas (urban and rural) in Peninsular Malaysia were collected. Age/sex- and body surface area/sex-specific upper limits (97th percentile) of normal thyroid volume were derived. Thyroid ultrasonographic data of similar-age children from schools located in a mildly iodine-deficient area, a severely iodine-deficient area, and a non-iodine-deficient area were also collected; spot urines were obtained from these children for iodine determination. RESULTS: The goitre prevalences obtained using the local reference were consistent with the median urinary iodine concentrations in indicating the severity of IDD in the areas studied. In contrast, the results obtained using the WHO/ICCIDD-recommended reference showed lack of congruency with the median urinary iodine concentrations, and grossly underestimated the problem. The local sex-specific reference values at different ages and body surface areas are not a constant proportion of the WHO/ICCIDD-recommended reference. A further limitation of the WHO/ICCIDD-recommended reference is the lack of normative values for children with small body surface areas (<0.8m2) commonly found in the developing countries. CONCLUSION: The observations favour the use of a local reference in the screening of children for thyroid enlargement.     

Thyroid volumes and urinary iodine in Swiss school children, 17 years after improved prophylaxis of iodine deficiency

Salt iodine content in Switzerland was raised from 7.5 to 15 mg per kg in 1980, and since then dietary iodine intake has been considered to be sufficient, even though a slight decrease due to imported food has recently been reported. The aim of this study was to establish normal values for thyroid volumes of school children who can be assumed to have had a sufficient iodine intake all their lifetime. Moreover. the present investigation was undertaken to verify that iodine sufficiency had been achieved equally in two regions each served by one of the two Swiss salt producers. Mean iodine concentration in urine spot samples from school children was 16.1 microg/dl, and it was identical in both the city of Lausanne (n=215) and the city of Solothurn (n=208). Thus it can be stated that in both cities (served by two different salt producers) iodine intake is equal and sufficient. Accordingly, thyroid volumes measured by ultrasound in school children aged 6 to 16 years were the same in both Lausanne (n=202) and Solothurn (n=207). Moreover, the age-adjusted median volumes at the 97th percentiles closely agree with and validate provisional international reference values recently proposed by the World Health Organisation and by the International Council for Control of Iodine Deficiency Disease.     

Thyroid ultrasound compared with World Health Organization 1960 and 1994 palpation criteria for determination of goiter prevalence in regions of mild and severe iodine deficiency

OBJECTIVES: In 1994, WHO/International Council for the Control of Iodine Deficiency Disorders recommended replacing the WHO 1960 four-grade goiter classification with a simplified two-grade system. The effect of this change in criteria on the estimation of goiter prevalence in field studies is unclear. In areas of mild iodine deficiency disorders (IDD) where goiters are small, ultrasound is preferable to palpation to estimate goiter prevalence. However, in areas of moderate to severe IDD, goiter screening by palpation may be an acceptable alternative to thyroid ultrasound. To address these two issues, we compared WHO 1960 and 1994 criteria with thyroid ultrasound for determination of goiter prevalence in areas of mild and severe IDD in Morocco. DESIGN: A cross-sectional study of 400 six- to 13-year-old children from two mountain villages (Ait M'hamed and Brikcha) in rural Morocco was carried out. METHODS: Urinary iodine concentration (UI), whole blood TSH and serum thyroxine were measured. Thyroid size was graded by inspection and palpation by two examiners using both WHO 1960 and 1994 criteria. Thyroid volume was determined by ultrasound. Variation between examiners and examination methods was assessed. Sensitivity and specificity of the two classification systems compared with ultrasound were calculated. RESULTS: Median UIs in A?t M'hamed and Brikcha were 183 and 24 microg/l respectively. In Ait M'hamed, using 1960 and 1994 criteria, goiter prevalence was 21 and 26% respectively, compared with 13% by ultrasound. In Brikcha, with 1960 and 1994 criteria, goiter prevalence was 64 and 67% respectively, compared with 64% by ultrasound. Agreement between observers was better with the 1994 criteria than with the 1960 criteria in Ait M'hamed (kappa=0.53 and 0.47 respectively), while in Brikcha observer agreement was similar with the two systems (kappa=0.67). Using either the 1994 or 1960 criteria, agreement with ultrasound was only moderate in Ait M'hamed (kappa=0.41-0.44), but good in Brikcha (kappa=0.55-0.64). Overall, compared with ultrasound, sensitivity increased 3-4% using 1994 criteria, while specificity decreased 4-5%. CONCLUSIONS: The WHO 1994 criteria are simpler to use than the 1960 criteria and provide increased sensitivity with only a small reduction in specificity. Agreement between observers is better with the 1994 criteria than with the 1960 criteria, particularly in areas of mild IDD. Like the 1960 criteria, the 1994 criteria overestimate goiter prevalence in areas of mild IDD, compared with ultrasound. However, the 1994 palpation criteria provide an accurate estimate of goiter prevalence in areas of severe IDD, and may be an acceptable and affordable alternative to thyroid ultrasound in these areas.     

Determination of iodine concentration in urine by isotope dilution analysis and thyroid volume of school children in the west coast of Turkey after mandatory salt iodization

OBJECTIVE: This study was designed to evaluate iodine deficiency status in children 6-12 years in the west coast (Aegean Region) of Turkey after 5 years of mandatory iodine prophylaxis. A total of 2300 children from 72 populations (rural and urban area) were evaluated with urinary iodine excretion and thyroid volume. DESIGN: Cross-sectional, observational study designed and performed according to surveillance methods for iodine deficiency disease (IDD) prevalence recommended by WHO/UNICEF/ICCIDD. SUBJECTS: The study population consisted of 2300 school children age ranging from 6 to 12 years. The children were selected by multiple stage randomization from 91 primary schools of 76 zones (91 clusters). Information about the use of iodized salt was obtained from the families. MEASUREMENTS: Data on the following were collected: birth date, sex, weight, height, thyroid size by palpation and ultrasonography; and urinary iodine by isotope dilution analysis method. Thyroid volumes above 97th percentile according to the WHO/ICCIDD by age and body surface area (BSA) were accepted as goitre. RESULTS: Iodized salt consumption was 51.7%. The prevalence of goitre determined by palpation was 12.1% and by ultrasound based on BSA and age were 9.8% and 5.5%, respectively. Median urinary iodine was 53 (2-142) microg/l. CONCLUSION: Mild to severe degree of iodine deficiency was detected in the west coast of Turkey.     

Thyroid ultrasound is the best prevalence indicator for assessment of iodine deficiency disorders: a study in rural/tribal schoolchildren from Gujarat (Western India)

OBJECTIVES: (i) To assess the severity of iodine deficiency disorders (IDD), (ii) to determine the aetiology of IDD in Gujarat, (iii) to identify the best prevalence indicator of IDD, and (iv) to compare thyroid volume (TV) results with the WHO International reference. METHODS: Five hundred and thirty schoolchildren (6-15 years) were studied from two districts (Baroda and Dang) and data were collected on dietary habits and parameters such as height, weight, thyroid size by palpation and ultrasonography, urinary iodine (UI), and blood thyroid stimulating hormone (TSH). Drinking water was analyzed for iodine content and food articles for goitrogens. RESULTS: In Gujarat children median UI (interquartile range)=56 (30-96)microg/l, mean TSH=1.71 +/- 2.10mU/l, goiter by palpatio n = 30%, and median TV = 27.8 (23-35)ml. Females had lower median UI (48 (27-82) microg/l) and higher mean TSH levels (2.0 +/- 2.5mU/l) than males. Applying the WHO ultrasonography reference to Gujarat children resulted in an enlarged TV-for-body surface area in almost 100% of subjects. Ninety-nine percent of females and 95% of males had enlarged TV-for-age. Three to eight times larger TV were seen in all subjects as compared with European children. Dang children were severely malnourished. Flavonoids like vitexin, glucosyl vitexin and apigenin were detected in pearl millet. Apigenin was never identified in pearl millet. Dang district water was lacking in iodine content. CONCLUSIONS: IDD is a severe public health problem in Gujarat. Baroda district is a new pocket of IDD. High amounts of dietary flavonoids in Baroda and Dang districts, and lack of iodine in Dang water, account for IDD. TV measurement by ultrasound is the best prevalence indicator of IDD.     

World Health Organization/International Society for Biomedical Research on Alcoholism study on state and trait markers of alcohol use and dependence: back to the future

This article summarizes content proceedings of a symposium held at the 2004 International Society for Biomedical Research on Alcoholism Congress in Mannheim, Germany. The chairs were Boris Tabakoff and Friedrich M. Wurst. The presentations were (1) Genetic associations with alcoholism and affective disorders, by Paula Hoffman; (2) Proteomic analysis of blood constituents in alcoholism, by Boris Tabakoff; (3) Contrasts between the responses of GGT and CDT to high alcohol intake, and a test of their combined use, by John Whitfield; (4) Direct ethanol metabolites such as ethyl glucuronide, fatty acid ethyl esters, phosphatidylethanol and ethyl sulfate: a new line of sensitive and specific biomarkers, by Friedrich Martin Wurst; and (5) Genetic studies of alcoholism subtypes in a Han Taiwanese population, by Ru-Band Lu.     

Clinicopathological comparison of the World Health Organization/Wotherspoon score to the Groupe d'Etude des Lymphomes de l'Adult grade for the post-treatment evaluation of gastric mucosa-associated lymphoid tissue lymphoma

Background and Aim:  The World Health Organization (WHO) has adopted criteria for the histological differential diagnosis of gastric extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (GML) based on the criteria proposed by Wotherspoon in 1993 (WHO/Wotherspoon score). These histological criteria are commonly used by pathologists for initial diagnoses, but have not been adopted uniformly for the post-treatment evaluation of GML. In 2003, the Groupe d'Etude des Lymphomes de l'Adult (GELA) proposed a new histological grading system (GELA grade) in preference to use of the WHO/Wotherspoon score for post-treatment evaluation. In the present study, we compared the WHO/Wotherspoon and GELA systems to examine which histological criterion is better for post-treatment evaluation.
Methods:  Fourteen cases of GML under long-term follow up were initially diagnosed according to the WHO criteria with detailed immunohistology, and were periodically evaluated with both histological criteria after anti- Helicobacter pylori treatment. They were also evaluated based on histological stromal changes accompanying the disappearance of lymphoma tissue.
Results:  The study showed strong similarities between the WHO/Wotherspoon and GELA systems and no clear advantage of either system for post-treatment evaluation. The GELA grade could not be used for the evaluation of changes in the degree of lymphoma infiltration from pre- to post-treatment because the four-item scale is not comparable with the formal six-point WHO/Wotherspoon scale. Stromal changes in the lamina propria, including an empty appearance and fibrosis, were correlated with lymphoma reduction after treatment and appear to be good indicators for post-treatment evaluation.
Conclusion:  We propose the utilization of the WHO/Wotherspoon score accompanied by the assessment of stromal changes for the post-treatment evaluation of GML.     

European framework for tuberculosis control and elimination in countries with a low incidence. Recommendations of the World Health Organization (WHO), International Union Against Tuberculosis and Lung Disease (IUATLD) and Royal Netherlands Tuberculosis Association (KNCV) Working Group.

As countries approach the elimination phase of tuberculosis, specific problems and challenges emerge, due to the steadily declining incidence in the native population, the gradually increasing importance of the importation of latent tuberculosis infection and tuberculosis from other countries and the emergence of groups at particularly high risk of tuberculosis. Therefore, a Working Group of the World Health Organization (WHO), the International Union Against Tuberculosis and Lung Disease (IUATLD) and the Royal Netherlands Tuberculosis Association (KNCV) have developed a new framework for low incidence countries based on concepts and definitions consistent with those of previous recommendations from WHO/IUATLD Working Groups. In low-incidence countries, a broader spectrum of interventions is available and feasible, including: 1) a general approach to tuberculosis which ensures rapid detection and treatment of all the cases and prevention of unnecessary deaths; 2) an overall control strategy aimed at reducing the incidence of tuberculosis infection (risk-group management and prevention of transmission of infection in institutional settings) and 3) a tuberculosis elimination strategy aimed at reducing the prevalence of tuberculosis infection (outbreak management and provision of preventive therapy for specified groups and individuals). Government and private sector commitment towards elimination, effective case detection among symptomatic individuals together with active case finding in special groups, standard treatment of disease and infection, access to tuberculosis diagnostic and treatment services, prevention (e.g. through screening and bacille Calmette-Guéria immunization in specified groups), surveillance and treatment outcome monitoring are prerequisites to implementing the policy package recommended in this new framework document.