Features of the Clinical Presentation, Diagnosis of Thyroid Diseases in Adolescents, and Issues of Rehabilitation

The research is dedicated to the study of the clinical features, diagnosis, and rehabilitation of thyroid diseases in adolescents. The relevance of the work is conditioned by the high prevalence of thyroid pathology among the pediatric and adolescent population, particularly in iodine-deficiency regions, as well as by the significant impact of thyroid gland functional disorders on intellectual development and the general state of health of the growing organism. Within the framework of the research, a comprehensive assessment of the structure of thyroid pathology, the informativeness of various diagnostic methods, and the development of a medical monitoring system for adolescents with thyropathies were conducted.

A three-tier system of monitoring the health of adolescents with thyroid diseases has been proposed, which includes problem-targeted education of students and their parents in a specialized "Thyroid School," preventive measures, and individualized therapy. The obtained data allow an assessment of the most informative diagnostic approaches and substantiate the necessity of a comprehensive approach to the rehabilitation of adolescents with thyropathies, including pharmacological treatment, educational programs, and permanent endocrine observation.

RELEVANCE. Thyroid diseases occupy a leading position among all endocrine pathologies in children, with diffuse nontoxic goiter holding the first place in their structure. Given the specific dependence of mental processes on the level of thyroid hormones in the blood, it is difficult to overestimate the harm inflicted by thyroid pathology on the intellectual potential of society (Shcheplyagina L.A., 1997; Kasatkina E.L., 1997; Baranov A.A., 1998; Kandor V.I., 1999; Gerasimov G.A., 2001). All this necessitates the urgent resolution of this problem. However, a number of unresolved questions still exist: there is no unified, universally accepted classification that would reflect the diversity of forms (heterogeneity) of goiter. There is no clear delineation of terms defining epidemiological and nosological concepts, which should be not only substantive but also evidence-based (Lisenkova L.A., Gulyaev A.I., 1991; Zykova T.A. et al., 1996; Kravets E.B., 1996; Kasatkina E.P., 2001; Lushnikov E.F., 2002). The questions of diagnosis and treatment of autoimmune thyroiditis and nodular goiter have not been fully clarified (Melnichenko G.A., 2002). Approaches to the diagnosis and treatment of nodular goiter widely used in domestic clinical practice often do not meet the requirements of modern evidence-based medicine, which takes into account both the clinical and economic effectiveness of diagnostic interventions and, most importantly, the remote prognosis of the disease and the influence of medical interventions on it (Fadeev V.V., 2002).

The problem of goiter has concerned minds throughout the entire history of humankind. The interest of the global community in this problem is great and is conditioned by the circumstance that the state of health and the intellectual level of the population residing in iodine-deficiency regions is lower than in regions free from goiter endemicity (Anfinogenova O.B., 1997; Kasatkina E.L., 2001; Makulova N.D., 2001; Nico Bleichrodt, Marise Ph. Born, 1999).

Iodine deficiency, even at a mild degree of manifestation, serves as a triggering mechanism of many thyroid diseases, such as nodular and mixed goiter, thyroiditis (Shcheplyagina L.A., 1997). The role of thyroid hormones is especially great in childhood and adolescence — the growing organism requires a relatively larger quantity of them than in adults.

It is known that the pubertal period acts as a natural load test, a functional trial. At this age, all previously hidden defects become apparent. This fact determines the relevance and socio-medical significance of thyroid pathology in the adolescent period. It is precisely during this period that careful preventive medical supervision is required (Zhdanova L.A., Rusova T.V., 1998).

The existing scheme for detecting thyroid diseases is labor-intensive and requires improvement. A comprehensive assessment of the health of adolescents with thyropathies is absent. Principles for the rehabilitation of these patients have not been developed.

Objective of the research: To develop a unified, comprehensive system of medical monitoring of the health status of adolescents with thyroid diseases.

Tasks of the research:

1. To study the epidemiological characteristics of the expression of iodine deficiency in Tomsk, to determine the structure of thyroid pathology and the health status of adolescents with thyroid diseases.

2. To clarify the degree of informativeness of clinical, metabolic, hormonal, and ultrasonographic parameters in terms of the diagnosis and prognosis of thyropathies.

3. To evaluate the effectiveness of problem-targeted education of adolescents in a specialized school for patients with thyroid pathology and to develop a program for monitoring their health.

4. To create an algorithm for forecasting the effectiveness of treatment of endemic goiter.

Scientific novelty

For the first time, the structure of thyroid pathology among adolescents of the city of Tomsk and the Tomsk Region is presented. A comprehensive clinical-functional-morphological characterization of thyropathies is given. The features of somatic health of adolescents with thyroid diseases have been studied. It has been established that thyroid pathology is most often represented by endemic goiter, with autoimmune thyroiditis occupying the second place and nodular goiter the third.

The degree of iodine deficiency in the city of Tomsk has been evaluated. A mild degree of deficiency has been established based on the level of iodine excretion in urine, with a median ioduria of 73.1 mcg/L; the prevalence of goiter was 41.2%, and according to WHO criteria (more than 30%), this corresponds to a severe degree of iodine deficiency. The discrepancy between the prevalence of goiter and the degree of iodine insufficiency indicates the existence of additional goitrogenic factors in the conditions of a modern industrial city, acting in parallel with the natural deficiency of the microelement.

It has been established that the health status of adolescents with thyropathies is characterized by frequent chronic somatic disorders compared to adolescents without thyroid pathology, in such classes as diseases of the digestive organs, nontoxic endocrine pathology (obesity, hypothalamic dysfunction).

The informativeness of various methods of diagnosis of thyropathies has been determined. It has been proven that the most informative, sufficient, and economically effective methods for the differential diagnosis of endemic goiter and autoimmune thyroiditis are: in the clinical blood test, hemoglobin and lymphocyte indicators; ultrasonography of the thyroid gland; determination of thyrotropic hormone (TSH), thyroxine, and antibodies to thyroid peroxidase in serum blood.

For the first time, a three-tier system of monitoring the health status of adolescents with thyroid diseases has been developed and implemented, including problem-targeted education of adolescents and their parents, prevention and treatment, based on a created model for forecasting the effectiveness of the conducted therapy.

Practical significance

The data obtained as a result of the conducted research (assessment of the health status of adolescents with thyropathies, analysis of treatment effectiveness) made it possible to develop a three-tier system of health monitoring, a unified tactic of rehabilitational measures for adolescents with thyropathies, and to substantiate the necessity of implementing problem-targeted education in the "Thyroid School" for sick children and their relatives. It has been proven that the best results in the treatment of thyroid diseases have been achieved among adolescents who have undergone training in the Thyroid School and are regularly observed by an endocrinologist who follows all physician recommendations. The developed model for forecasting the effectiveness of therapy treatment allows a differentiated approach to the prescription of treatment for endemic goiter. Conducting levothyroxine therapy leads to a controlled course of autoimmune thyroiditis.

Implementation of the research results

The results of the research have been implemented in the practice of organizing endocrine care for children and adolescents in the regional endocrine dispensary and are used in the process of training students at the State Medical University. A school of problem-targeted education for patients with thyroid diseases, the "Thyroid School," has been implemented in the regional endocrine dispensary. Based on the results of the research, methodological recommendations for monitoring the health of adolescents with thyroid diseases have been developed.

Theses for defense

1. The study of thyropathies in adolescents using a complex of clinical, functional, and morphomorphological research methods provided grounds to present the structure of thyroid diseases in adolescents.

2. The somatic health of adolescents with thyropathies is characterized by polyorganic changes: hepatobiliary and gastroenteric systems, nontoxic endocrine pathology (obesity, juvenile diathetism).

3. The most informative of the instrumental-laboratory criteria for assessing the state of the thyroid gland in diffuse nontoxic goiter are the investigation of TSH, T4, and ultrasonography of the thyroid gland.

4. One of the important directions for the health improvement of adolescents with thyropathies is the organization of a three-tier system of medical monitoring of their health.

Presentation of the work

The results of the work were reported at the Interregional Scientific Conference of Young Scientists (Tomsk, 1998), the Interregional Scientific and Practical Conference of Siberia and the Far East dedicated to the 150th anniversary of the birth of Academician I.P. Pavlov (Tomsk, 1999), the conference "Health of Children Is Our Future" (Tomsk, 2000); the All-Russian Scientific and Practical Conference "Actual Problems of Thyroid Diseases" (Moscow, 2000); the IX Congress of Russian Pediatricians "Child Health Care in Russia: Development Strategy" (Moscow, 2001), the section "Informatization in Medicine and Pharmacy" of the 3rd Scientific and Practical Conference "Modern Tools and Automation Systems — Guarantee of High Production Efficiency" (2002, TUSUR); the 9th International Scientific and Practical Conference "Modern Techniques and Technologies" (Tomsk, 2003), at the First All-Russian School-Seminar of a Pediatric Endocrinologist: "New Opportunities for Diagnosis and Therapy of Endocrine System Diseases in Children" (Tomsk, 2003).

Publications. Twelve works have been published on the topic of the dissertation, including four in the central press.

Volume and structure of the dissertation

The dissertation is presented on 183 pages of typed text, consists of an introduction, five chapters, a conclusion, conclusions, practical recommendations; the bibliographic reference list includes 290 sources (198 domestic and 92 foreign authors), illustrated with 24 tables and 12 figures.

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