CRAW LOCAL (grech, endemos local, inherent to this area; synonym local goitrous disease) — the disease which is characterized by an enlargement of the thyroid gland, various clinical manifestations and affecting the population of certain geographical areas with insufficiency of iodine in the environment.
3. aa. it was known to doctors of antiquity. Its development contacted accommodation in the mountain area and a poor quality of drinking water; for treatment 3. aa. algas, sea salt, operational methods were used. Within the last 100 years 3. aa. it was widely studied in the different countries. Essential contribution to development of problem 3. aa. the proposal in
1856 of fr. doctors of the Brown-haired person was (G. And. Chatin) and Prevo (J. L. Prevost) to carry out the iodic prevention which afterwards is theoretically proved in works of B in districts of an endemia of a craw. I. Vernadsky, Fellenberg (T. Fellenberg), D. Marine, H. Eggenberger and other researchers. In Russia pioneers of studying 3. aa. were M. F. Kondaratsky, To. Shalygin, N. I. Kashin, etc.
After Great October socialist revolution a solution 3. aa. became a national objective. Basic researches of epidemiology, an etiology, pathogeny, clinic and treatment 3 were conducted. aa. The big role in it was played by O. V. Nikolaev, B. V. Alyoshin, A. N. Vinogradov, I. K. Akhunbayev, R. K. Islambekov, A. T. Lidsky, A. N. Syzganov, I. X. Turakulov, etc. Since 30th mass iodic prevention is carried out to the USSR, the system of antigoitrogenic clinics which activity is directed to studying of epidemiology 3 is created. aa. and organization of events on its prevention and treatment. The social and economic changes which happened in the USSR antigoitrogenic actions allowed to liquidate 3. aa. as a mass disease already to the middle of the 50th
3. aa. is the most widespread disease of a thyroid gland. According to WHO data (1960), on the globe is apprx. 200 million such patients. An endemia of a craw meet as in mountain (The Alps, Altai, the Andes, the Himalayas, the Caucasus, the Carpathians, the Cordilleras, Tien Shan, etc.), and in flat districts (the tropical districts of Africa, South America, the country of Eastern Europe). In the USSR districts of an endemia are the Western Ukraine, Polesia, upper courses of Volga, Ural, Central and North Caucasus, some districts of Central Asia, Altai, a number of the Regions of Transbaikalia and the Far East, valley of the big Siberian rivers. Districts of an endemia of a craw are biogeochemical, provinces with insufficiency of iodine in the biosphere. The district is considered endemic if more than 10% of the population have a wedge, symptoms of a craw. 3. aa. meets at women more often, however in districts of a heavy endemia it is observed also often and at men. An endemia of a craw differ on weight. The endemia is considered heavy if frequency 3. aa. it is higher than 60%, Lenz's index — Bauer (the attitude of number of sick men towards number of sick women) 1: 3 — 1: 1, the frequency of nodal craws is higher than 15%, cases of cretinism meet. The endemia is considered average with a frequency of 3. aa. it is higher than 30%, Lenz's index — Bauer 1: 6 — — 1:3, the frequency of nodal forms 3. aa. it is higher than 5%. The endemia is considered easy with a frequency of 3. aa. it is higher than 10%, Lenz's index — Bauer 1: 6 and above, the frequency of nodal forms to 5%, at preferential hyper thyroid course of a disease.
Reason of development 3. aa. the iodine deficiency in the biosphere is that visually is confirmed by experimental data, results geochemical, the analysis and progress of prevention 3. aa. iodized salt and drugs of iodine. In addition to iodic insufficiency, in the centers of an endemia of a craw there is a number of the factors promoting manifestation and development of a craw: receipt in an organism of various goitrogenic substances (thiocyanates, viniltiooksizolidin — connections goetrin, progoitrin, Brassica which are contained in some vegetables of a look) and iodine in a form, unavailable to absorption (at high content in water and the soil of humin substances), the inherited disorders of iodic exchange resulting in relative iodic insufficiency: a high level of renal clearance, the reduced half-life of thyroxine. There is an opinion that in an origin 3. aa. increase or reduction of contents in the biosphere of cobalt, molybdenum, copper, zinc, mercury matters; a certain part in emergence of goitrous transformation is assigned to calcium. To number external etiol, factors refer bacterial and helminthic impurity of the environment that allowed Me Carrison to put forward the toxi-infectious theory of an etiology 3. aa., however attempts to allocate the microbic activator 3. aa. were unsuccessful. Manifestation of iodic insufficiency can be promoted various fiziol, states (the pubertal period, pregnancy, a lactation) and intercurrent diseases.
Iodic insufficiency leads a pathogeny to decrease in secretion and products of thyroid hormones. Deficit of these hormones causes in an organism development of the compensatory and adaptive reaction directed to maintenance of a hormonal homeostasis and which is expressed in activation of thyritropic function of a hypophysis, a hypertrophy and a hyperplasia of tirotsit, increase in capture of iodine a thyroid gland, acceleration of iodination of tyrosines and increase in formation of yodtironin (generally triiodothyronine). All this provides preservation of an euthyroid state (see. Euthyroidism ). Increase in level of yodtironin in blood oppresses thyritropic function of a hypophysis and indirectly secretory activity of a thyroid gland that causes development hypothyroidism (see). At influence of certain factors perhaps permanent increase in function of a thyroid gland and development of a hyperthyroidism. On the basis of a community of a pathogeny and clinic 3. aa. and craw sporadic (see) are considered by a number of researchers as kinds of a uniform disease.
The pathological anatomy is characterized by presence of three morfol, forms 3. aa.: diffuse (diffusion), nodal (nodose) and mixed (diffusion and nodal). At the beginning of a disease the diffusion form with uniform increase in gland at not changed its contours is observed. Formation of the separate centers of proliferation leads to development of the nodal or mixed form of a craw. At a nodal hyperplasia multiple nodes, various in a form, badly delimited from surrounding fabric, but keeping a tendency to growth sometimes are found. Microscopically 3. aa. geterogenen. The diffusion craw is presented by normal or microfollicular fabric. Depending on a functional state follicles contain the basphilic, «dense» or only translucent, almost transparent eosinophilic colloid. At rest an epithelium of follicles cubic or flat; in a condition of functional activity it becomes high, light, forms sosochkovidny protrusions in a cavity of a follicle (fig. 1). In diffusion and nodal craws structures meet trabecular and tubular «. It is supposed that than the endemia of a craw is heavier, subjects malodifferentsirovanyay forms of a parenchymatous craw meet more often (tubular and trabecular). The colloid craw is constructed of follicles of various size (macro - and microfollicular), rich with the colloid giving positive reaction to RNA, proteins and mucopolysaccharides. The combination of follicles of various size creates a motley picture of a colloid craw (fig. 2 and Z). In craws involutional changes (hemorrhages, dystrophic processes) with further adjournment in the changed sites of lime and cholesterol can be found. Parenchymatous and colloid forms of a craw can be transformed to a fibrous form with increase in connective tissue educations. Solitary adenomas (nodes) are exposed to various involutional changes in connection with special type of blood circulation quicker. The nodal craw can be exposed to a malignancy. Though there are no enough convincing data that 3. aa. it malignizirutsya more often in comparison with sporadic, however solitary adenoma in the conditions of an endemia of a craw is considered as a problem oncological.
The clinical picture
the Clinical picture is defined by a form and size of a craw, and also a functional condition of a thyroid gland. Usually patients complain only of cosmetic inconveniences. Sometimes they note pressure in a neck (the woman more often in the period of periods, emotional stresses).
3. aa. differs on degree of an enlargement of the thyroid gland (see. Craw ). At an enlargement of the thyroid gland of the I—II degree people reckon with disorders of function of gland or with a nodal form of a craw as sick. Clinically the diffusion, nodal and mixed forms 3 come to light. aa. At a diffusion form of iron it is increased evenly in both shares, elastic, well mobile during the swallowing, painless at a palpation. Sometimes in iron find separate consolidations — small adenomas. The nodal form is characterized by existence of one or several nodes, various on localization and the sizes. In the latter case it is about a conglomerate craw. At a palpation nodes of various density and mobility are defined. The arrangement of a craw happens atypical that is connected with options of embryonic development of a thyroid gland. Sometimes the size and the provision of a craw are that that cause a prelum of the next bodies (tracheas, a gullet, blood vessels). The disturbances of blood circulation connected with a compression of vessels can lead to vasodilatation of a neck and a front surface of a thorax that is more often observed at a retrosternal craw and is followed by symptoms of a prelum of a recurrent nerve and Bernard's symptom complex — Horner (see. Bernard — Horner a syndrome ). A functional condition of a thyroid gland at 3. aa. in most cases euthyroid, however long existence of a craw can lead to depression of function of a thyroid gland and development of a hypothyroidism. In districts of a heavy endemia in the past patients with local quite often met cretinism (see). In districts of an easy and average endemia it is possible to meet 3 more often. aa. with a hyper thyroid current. At an euthyroid craw the clinic of «goitrous» heart which is characterized by disturbances of blood circulation with simultaneous disturbance of breath, increase in blood pressure in a small circle of blood circulation, a hypertrophy and expansion of the right heart, sometimes a high tooth of P on an ECG is sometimes observed. Complication 3. aa. are strumites (see). At hemorrhage in a craw its sizes quickly increase, it becomes intense, painful, fluctuation sometimes is defined. Calcification of a craw is observed rather seldom. The malignancy of a craw is possible, to a cut aberrant forms are more inclined.
the Diagnosis is based on data of the anamnesis (residence in endemic districts), survey, a palpation of a thyroid gland. Laboratory and functional researches of a thyroid gland (definition of standard metabolism, content of the proteinaceous and connected iodine, cholesterol and general thyroxine in a blood plasma) at an euthyroid form 3. aa. do not define aberrations more often. Absorption of a radioiodine a thyroid gland can be raised (see. Thyroid gland, radio isotope research ). Test with thyritropic hormone of a hypophysis finds insignificant or total absence of increase in absorption of radioiodine. Differential diagnosis 3. aa. it is carried out with craw diffusion toxic (see) and subacute hron, thyroidites (see). Sometimes 3. aa. it is necessary to differentiate with tumors of a carotid sine, a retrosternal craw — with tumors and dermoid cysts of a mediastinum. The research helps with these cases rentgenol (see. Thyroid gland ) or a research by means of a radioiodine. To distinguish 3. aa. and cancer of a thyroid gland difficult. A sign of a malignancy of a craw is its rapid and uneven growth, limited mobility, change of phonation of a voice. Low-mature forms of cancer can not absorb a radioiodine, but well absorb radioactive phosphorus that is a differential diagnostic character.
Treatment depends on a form of a craw, a functional condition of a thyroid gland and associated diseases. In case of diffusion 3. aa. at small degree of an enlargement of the thyroid gland drugs of iodine are effective. Iodine is shown in a dose no more than 500 mkg a day (usually 200 — 300 mkg) within 3 months (antistrumin, one tablet appoint to-rogo contains 500 mkg of iodine). If the positive effect is not defined, treatment is stopped, prolonged use of high doses of iodine can lead to development of a hyperthyroidism — «iodine-bazedov». In this case, and also at hypothyroid 3. aa. therapy is shown by thyroid hormones and drugs of a thyroid gland. Their use individually also depends on age of the patient, existence at it arterial hypertension, cardial disturbances. Thyreoidinum is appointed inside usually on 0,1 g a day or every other day, at a large craw and good tolerance of drug the dose can be sometimes raised to 0,2 — 0,3 g a day. Treatment by Thyreoidinum usually continues within 4 — 8 months, sometimes several years and stops after achievement of effect. Treatment by thyroxine (on 200 mkg a day) is also effective and is carried out within 4 — 8 months. Also use of triiodothyronine is shown: an initial dose of 10 — 20 mkg gradually increase under control fortunes of the patient to 40 — 60 mkg. At increase in function of a thyroid gland thyreostatic drugs are used (see. Anti-thyroid means ).
At the nodal, mixed and diffusion form of a craw of the IV—V degree which is followed by the phenomena of a prelum of bodies of a neck at an atypical arrangement of a thyroid gland, at a craw with the expressed destructive changes (fibrosis, hemorrhages, calcification) operational treatment is absolutely shown. Preoperative preparation includes purpose of Thyreoidinum. In the USSR the technique of a subtotal subfascial resection of a thyroid gland was widely adopted (see. Craw diffusion toxic ).
the Forecast favorable, at a malignancy of a craw doubtful. Working capacity at euthyroid 3. aa. remains, at change of function of a thyroid gland decreases.
The lethality after operation for a craw makes 0,25 — 1%, according to de F. de Quervain. Long-term results in most cases favorable. During the performing postoperative iodic prevention by antistrumin on 1 tablet 2 times a week the frequency of a recurrence of a craw considerably decreases.
Prevention comes down to use in districts of an endemia of the iodated sodium chloride containing according to standards of the USSR 25 g of potassium iodide in one ton of salt (mass, or mute, prevention). It is approved by M3 of the USSR and is carried out in all districts of an endemia from 1930th San. - epid. stations in districts of an endemia and antigoitrogenic clinics carry systematically out control of the content of potassium iodide in sodium chloride, its storage, transportation. Iodized salt is applied also as top-dressing to the cattle that increases the content of iodine in meat-and-milk products (80% of daily amount of iodine come to a human body with food). In organized collectives, among children, at pregnant women and nursing mothers group prevention is carried out by antistrumin. In the USSR use of mass and group prevention and basic changes of social and economic living conditions allowed to liquidate 3. aa. as mass disease.
In the tropical countries in prevention 3. aa. intramuscular introduction 2 — 3 times a year of the iodated solution of oil is used, in the countries of the Far East in food there are algas containing significant amounts of iodine (to 1 kg of a laminaria to 2 g).
Bibliography: Nikolaev O. V. Local craw, M., 1955; Odinokova V. A., Kondalenkov.F. imarder O. P. Light cells of a zobnoizmenenny thyroid gland, Arkh. patol., t. 30, No. 8, page 21, 1968, bibliogr.; The guide to clinical endocrinology, under the editorship of V. G. Baranov, page 428, L., 1977, bibliogr.; Turakulovya. X. Biochemistry and pathology of a thyroid gland, Tashkent, 1963; Hvorov V. V. Local craw, M., 1962; Khmelnytsky O. K., Raykhlin H. T. and Birov of V. V. Gistoenzimologiya of a thyroid gland, Arkh. patol., t. 36, No. 1, page 79, 1974, bibliogr.; A thyroid gland, Physiology and clinic, under the editorship of S. Verner, the lane with English, L., 1963; Local craw, the lane with English, M., WHO, 1963; Becker K. L. Management of thyroid disorders, Postgrad. Med., v. 53, No. 2, p. 60, 1973; Lab h art A. Klinik der inneren Sekretion, B. u. a., 1971; Means J. H., De G root L. J. a. Stanbury J. B. The thyroid and its diseases, N. Y., 1963; Ober-disseK. u. Klein E. Die Krankheiten der Schiladriise, Stuttgart, 1967.
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