Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Metabolic Maladaptation
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the risk population distribution. Thus, even when and if it were possible to iodize,
protect and deliver salt to the region, consumption patterns would mitigate against
achievement of the desired outcome.
The most successful method of control of goiter and cretinism in this population
turns out to be depot iodine repletion. Elemental iodine dissolved in poppyseed
oil at a concentration of 480 mg per ml is already constituted in a product called
Lipiodol, originally produced for lymphangiography. A depot injection of this iodized
oil intramuscularly can completely replete iodine stores to eliminate iodine
deficiency for a period of up to five years. 34 Compliance is not a problem, nor does
one have to worry that such iodization will not be shared with infants or childbearing
women since it is administered by the thyroid investigation team. Since the
team was in control of the injection process, the needles and syringes were sterilized
and the risk of HIV transmission was controlled by nonreusable needles that were
destroyed. There were no alternative sources of readily available iodine within this
population. In addition, there was essentially no traffic or commerce from outside
the group since there was no transport or marketing of any goods to outside groups
in a largely cash-less economy. There were no other iodine sources available for
barter within the Bas-Uele region.
Results of Depot Iodine Repletion Intervention
The population survey was completed for baseline determinations. Longitudinal
study was carried out through serial observations at quarterly intervals, except
when moved up to one month to avoid the most difficult travel periods within the
rainy season. Iodine repletion study was then begun for the treatment arm of the
population under surveillance. The independent variable was the injection of 480
mg of elemental iodine in one ml of poppyseed oil in adults; children were treated
with 0.5 ml, or 240 mg of iodine. Randomization was done by assignment from a
book of random numbers to the serial distribution of “latte”, or wooden tag amulets.
The treated group was compared with an untreated control population. The
measurements of goiter, thyroid function, and other morphologic measures are reported
herewith.
Measurements of thyroxin and TSH in one sample population of 50 patients are
seen in Table 2. In contrast with the baseline in the untreated population at time
zero, similar measurements done at six months and at three years following Lipiodol
injection showed a doubling of the mean thyroxin levels into normal range and a
six-fold reduction in mean TSH determinations. Thus, hypothyroidism was resolved
within a very short time following iodine repletion and remained in normal range
for three years.
In correlation with this change in thyroid hormone measurement that normalized
from hypothyroid ranges documented before treatment, changes were observed
in goiter that were equally impressive (Table 9). As noted when compared from
baseline control, goiter perimetry measures shrank remarkably when compared at
six months following Lipiodol injection, yet increased significantly once again by
the three years’ determination. At three years, the goiters were still remarkably smaller
than they were before treatment, but did not normalize as remarkably as the persistent
improvement in thyroid hormone determination.
Additionally there was a morphologic finding of an “escape” from the early beneficial
effects of iodine repletion on goiter size which was a surprise discovery. Nearly
all goiters uniformly shrank in their planimetry measures, but in serial observations
some appeared to escape this early control and regrowth was experienced, (see also
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