CORE - To Promote a Durable Radiological Protection Culture Among the Young People of the Bragin District by a Citizen Approach

Specific objective of the project was the improvement of rehabilitation of the patients with radiation induced thyroid cancer and other thyroid pathology in Stolin region by making the qualified medical aid more available at the place of patient's residence, increasing their life quality and social activity.
The specific objectives were:

1. Work out and implement a practical realization of the program of staged rehabilitation of patients with thyroid pathology in Stolin region. The program was grounded on the Health care abilities on the regional and Republican levels, as well as on shaping patients' co-participation by increasing their awareness of the course of their disease.
2. Investigate the demand and organize the supply of necessary medications (Levothyroxin, Calcium, Vitamin D and antioxidant complexes) for improved rehabilitation of patients.
3. Organize purchase of equipment for thyroid status monitoring to provide a possibility for local Stolin hospital to perform main analyses determining thyroid function.
4. Perform screening examinations of Stolin region population to reveal factors distinctive for Stolin region, affecting the development of thyroid pathology and worsening patients' condition (iodine and other microelement insufficiency, presence of pollutants).
5. Provide necessary conditions (computer purchase, Internet availability) for involvement of the Stolin Regional Territorial Medical Department (Stolin RTMD) in teleconsultations network in order to increase the quality of the medical aid.
6. Provide methodological assistance for improvement of qualification of doctors and nurses in the following areas: therapy and follow up of patients with thyroid cancer and other thyroid pathology, laboratory diagnostics, radiation safety and medical consequences of radiation exposure.
7. Prepare easily comprehensible brochures for the patients about thyroid diseases, healthy way of life, and organize patients' education in the regional hospital or out-patient department.

The project was carried out according to the specifications. The results were performed in five activities related to the objectives above mentioned:

Activity 1. Working out and carrying out of the program of staged rehabilitation of patients with thyroid cancer and other thyroid pathology in Stolin region.

Search and analysis of publications on the problem of rehabilitation of patients with thyroid cancer was continued. In general, over 200 publications collected.

The analysis of the modern scientific literature on the question of patients with radiation- induced thyroid diseases rehabilitation was performed.

A CD containing scientific publications of world leading journals (THYROID, European Journal of Endocrinology, Radiology, Journal of Clinical Endocrinology and Metabolism, Cancer ) dated 2005-2007 years was prepared on various thyroidological topics:

• Follow-up of patients with radiation induced thyroid cancer;
• Early diagnosis of thyroid cancer by ultrasound;
• Molecular-genetic methods of thyroid cancer diagnostics;
• Features of radiation induced diseases of a thyroid gland.

Brochures and booklets on different questions of thyroidology (patient's preparation for radioiodine therapy, goiter prophylaxis) and a textbook for patients The ABC for patients with thyroid diseases were issued.

A scheme of staged rehabilitation of patients with radiation induced thyroid cancer was worked out and tested at Republican level and regional hospital level.
 

Activity 2. Improvement of the logistics of the regional hospital and supply of the needed medications to the patients.

In 2006:

• Purchase of equipment and reagents of the DIALAB company. All the equipment was of high quality and sensibility for thyroid status monitoring in conditions of carrying out of the suppressive therapy with levothyroxine (June - July 2006).
• The equipment for immunoenzymatic hormone finding and reagents to the amount of 31 million Belarusian rubles were transferred to Stolin regional hospital (October).
• The seminar in training of laboratorial medical staff The usage of immunoenzymatic system of the DTATAB for thyroid hormone finding was held in Stolin regional hospital (1 - 5 October, 2006).
• Purchase of the reagents at the expense of budget financing in Stolin hospital was started in 2007:
• In the period from 01-01-07 to 01-12-07 over 518 thyroid hormone definitions were performed by the doctors of Stolin regional hospital. Stolin-Minsk serum exchange and constant quality control had been held.
• Computer hardware (computer, printer, scanner, web-camera) for teleconsultations for total amount of 3,2 million Belarusian rubles was purchased and transferred to Stolin regional hospital.
• Furniture for equipping of the working places of endocrinologist's and laboratory diagnostics doctors for total amount of 1,6 million Belarusian rubles was purchased and transferred to Stolin regional hospital.
• In 2007 payment for Internet provider assistance started for teleconsultations performance in Stolin regional hospital (0,7 million Belarusian rubles).
• Medications for the help to the patients with thyroid pathology for total amount of 10,2 million Belarusian rubles were purchased and are given to the patients at the moment of consultation free of charge.

Activity 3. Follow up of thyroid cancer patients and medical screening of the risk-group-population of Stolin region to reveal the real incidence of thyroid pathology at early stage.

Systematic follow up of thyroid cancer patients in accordance with the worked out scheme of staged rehabilitation, prevention of cancer relapses, early revealing of cancer relapses and other complications was held.

Doctors-endocrinologists performed constant monitoring of the state of thyroid function compensation in patients with radiation induced thyroid cancer, living in Stolin's and neighbouring Pinsk's and Luninets's regions.

Results of hormonal examination:

Constant monitoring of thyroid function was the base of successful rehabilitation. Estimation of Thyroid Stimulating Hormone (TSH) in 2007 revealed that by the first visit, TSH suppression (TSH<0,3 mIU/l) was observed only in 59% of patients, TSH within the normal range in 22%, TSH in the interval 4,0 to 10,0 mIU/I in 7,0% and TSH above 10,0 mIU/l in 11% of patients.

Amount of patients who have reached TSH suppression increased with every visit, what reflects endocrinologists work on levothyroxin dosage correction in accordance with thyroid hormones analyses results. Explanatory work on the importance of regular medication intake also plays an important role. In case of 1st visit, only 59% of patients had TSH levels below 0,3 mIU/l, then by the 4th visit sufficient TSH suppression was reached in 80%. A tendency for hypothyrosis rate decrease was observed from 11 to 2% by the 3rd visit. The group of hypothyroid patients still remains large: 20% (TSH>10 mIU/l) by the 4th visit. This fact was connected to that point that the most complicated patients who did not manage to normalize their thyroid status despite regular thyroxin intake were invited more often. Every case of such type was thoroughly followed up.

At initial visit, only 27% of patients had sufficiently low Tg levels (less than 1 ng/ml), by the 4th visit, this index was equal to 71%.

Thyroglobulin level from 1 to 5 ng/ml was detected in 42,5% of patients at initial visit and in 21% at the 4th visit. Tg level exceeding 5,0 and 10 ng/ml requires thorough analyses and follow up, and depends on Tg meanings at the moment of carcinoma detection and extent of expansion of the disease.
Conclusion of the activity:

1. Dynamic monitoring (in framework of thyroid school: explanatory work, prescription of an adequate dose of thyroxin and regular carrying out of hormonal investigation) allows improvement of follow up quality and reaching TSH suppression from 59% on primary examination - up to 80% by the 4th visit in thyroid cancer patients.
2. Low Tg levels (below 5 ng/ml) rate increases in dynamic follow-up from 69 to 92% and confirms remission.

Ultrasound screening of Stolin region risk-group-population: people affected by radiation at the age of less than 5 years old, pregnant women and children living on radionuclide contaminated areas:
In 2007, screening examination of Stolin's region inhabitants from radiation risk groups was continued. In total, 442 persons were examined in 2007 in the framework of mobile medical teams cooperating together with Stolin's doctors.

Below follows the analyses of thyroid pathology incidence revealed at screening for the cohort of patients examined in between 2006-2007 (898 patients in total).

Only 64% of screened patients had normal state of thyroid gland on examination, in the rest of them, 36%, different thyroid diseases were revealed. The most frequent pathology: autoimmune thyroiditis - 8,6%, hypothyroidism - 6,0%, nodular goiter - 4,8%. Ones attention was attracted by unusually high for the population level of thyroid hypoplasia and hypothyroidism prevalence. Thyroid hypoplasia was more frequently detected in female and thyroid enlargement in men. Further clarifying examination of patients with nodular goiter revealed 1 case of thyroid cancer.

In total, for 2 years of the project been held in the region, there were 14 new cases of thyroid cancer revealed (2006 - 8 cases, 2007 - 6 cases), what is significantly more, compared to the previously detected 1-4 cases in 2004 - 2005 year.

The highest prevalence of patients with thyroid pathology was seen in Stolin and Stolin's region. Only Nodular goiter was detected more frequently in the most radionuclide contaminated territory - village Olmany.

Thyroid hypoplasia was more frequently seen in patients irradiated "in utero" (11,8%), nodular and diffuse goiter were more frequent in patients irradiated "in utero" and in the first 3 years of age, compared to the non-irradiated-cohort. Hypothyroidism was 2 times more frequent in irradiated patients compared to the non-irradiated ones.

A very important fact revealed during the analysis: the highest frequency of thyroid hypoplasia (15%) was detected in patients who were irradiated at the 1st trimester of intrauterine development. Nodular goiter and multinodular goiter was more frequently detected in patients irradiated at the 3rd trimester of intrauterine growth (12,9%).

The main peculiarity of hormonal state in Stolin's region patient was high prevalence of persons with high titre of Anti-IPO antibodies - 11%, what proves a high level of autoimmune aggression readiness and forming a risk-group for autoimmune thyroiditis. Increased levels of Anti-IPO were detected in 14,1 % of female patients, what was significantly more frequent in comparison to male - 4,3%.
During the ultrasonic screening of thyroid gland, nodular pathology was revealed in 3,3% of cases, Autoimmune thyroiditis signs - in 8,2% of patients.. Thyroid hypoplasia was more frequently seen in females - 10% in comparison to males - 4,3%.

Ultrasonic examination of salivary glands revealed inhomogenity in 25,9% of submandibular salivary glands and in 5,3% parotid glands of Stolin's region inhabitants. Inhomogenity was more frequently detected among males The main reason for salivary gland inhomogenity was the detection of hyperechoic threads, what can reflect activity of fibrosing processes in the organ.

More frequently deviations of salivary gland ultrasonic appearance were detected among the examined patients of Olshany village (hyperechoic threads in 52% of cases) what can be the reflection of the ecological situation.

Reveal of reasons of high incidence of thyroid pathology and risk-factors determining its development in Stolin region:

With an aim of establishment of the reasons for high incidence of thyroid pathology in Stolin's region, it was performed an analysis of urine iodine concentration in patients from different settlements. Urine iodine concentration varied from 160 to 175 mircrog/l and was in between the WHO-recommended limits.

With the aim of revealing of the reasons for high incidence of thyroid gland pathology and the state of salivary gland among the Stolin's region inhabitants, it was performed a nitrate level determination in the drinking water from the opened wells in the villages Olmany and Olshany and from the water pipeline in Stolin. Nitrate levels were measured using a "Nitratemeater-PiAN-01" device, invented in the Department of Analytic Chemistry of Belarusian State University.

Significant exceeding of the Highest Allowed Levels (HAL) of Nitrate concentrations in the drinking water was detected in the villages Olshany and Olmany.

Analysis of the results received on Human-Radiation-Meter after the examination of more than 12 thousand persons in Stolin's region in 2006-2007, showed no significant excess of radionuclide accumulation. However, radionuclide concentrations (Bq/kg(l)) were significantly excessive in the food products: wild forest berries, mushrooms (fresh and especially dried ones), some milk and potato samples in the villages Olmany, Rechitsa, Luchitsa.

Activity 4. Involvement of Stalin region in to the teleconsultations network.

Constant Internet access on the base of the doctor-endocrinologist's cabinet was organized in the Stolin's region. Internet traffic was financed from the sources of the project. Users network for Internet-teleconsultations was formed. A training of medical personnel on the work with software was performed; constant consultative support on hardware and software was given. On March 22 - 24, 2007, first teleconsultations and TV-bridge Wuerzburg-Minsk-Stolin were performed Constant patient's teleconsultation sessions with the participation of Wuerzburg, Minsk and Stolin. Twenty patients were consulted in 2007.

Activity 5. Improvement of professional level of Stolin region medical workers and increasing of awareness of the patients about their disease.

In 2006 participation in 4 scientific seminars/workshops.

In 2007 participation in 7 scientific seminars/conferences/seminars.

16 Publications in conferences and scientific journals in 2006-2007.

Two CD-s were created:

1. Materials of Belarusian-German scientific practical conference "Diagnostics, treatment, prophylaxes of thyroid pathology and concomitant diseases in contemporary ecological conditions of Belarus"and "Arnica" projects realization chronicles".
2. Literature-review.

Conclusions

1. The rehabilitation-staging model of patients with thyroid cancer (regional level, republican level) including the determination of the hormonal status and its correction on regional level was developed and implemented in Stolin region.
2. Mobile brigades of Fund "Arnica" and doctors from Stolin regional hospital examined 190 animated patients with cancer and other thyroid diseases which were on suppression levothyroxine therapy and substantively improved the quality of medical care (the hypothyroidism frequency was lowered, the number of patients with reached suppressive level of TSH was raised).
3. On screening 898 subjects of the Stolins region were examined. According to findings the autoimmune thyroiditis - 8,6%, hypothyroidism - 6,0%, thyroid hypoplasia - 5,4% and nodular goiter - 4,8% were the most registered among examined subjects. Unusually high for general population levels of thyroid hypoplasia incidence, hypothyroidism and elevated autoantibody levels do attract attention. Thyroid cancer incidence in Stolin's region had a constant tendency to increase. The pathology among 80% of patients was reduced in the course of screening for the first time.
4. The main risk factors affecting thyroid diseases incidence revealed:
   • Irradiation "in utero", in the 1-st 3 months of fetus development increases the frequency of thyroid hypoplasia in the adult age.
   • Irradiation "in utero", in the 3-rd trimester of fetus development and at the early 3 years of age increases the risk of thyroid nodular pathology development.
   • Unfavorable ecological conditions (pollution of food with radionuclides and drinking water with nitrates) may forward to a thyroid and salivary gland pathology development.
5. The equipment for Fund Arnica (automobile – V W Iowan, computer, scanner, furniture, ultrasound machine) and Stolin regional hospital (IFA-analyzers DIALAB and reagents, computer, printer, scanner, office fruniture) was purchased.
6. Eleven conferences and seminars with more than 700 participants were held.
7. The project materials were published in 12 articles, 3 brochures, 3 CD were prepared for publication.