L’Apporto ottimale di iodio · Aghini Lombardi F et Al J Endocrinol Invest, 2013 May;36(5):282-6....

Roma, 7-9 novembre 2014

13°Congresso Nazionale AME Associazione Medici Endocrinologi 6th Joint Meeting with AACE American Association of Clinical Endocrinologists

Fabrizio Monaco

L’Apporto ottimale di iodio

”mai lesinare” (F. Monaco, CH) vs

“con qualche attenzione” (S. Corsello (RM)


1993 2013 110 countries iodine deficient 31 countries iodine deficient

13°Congresso Nazionale AME Associazione Medici Endocrinologi 6th Joint Meeting with AACE American Association of Clinical Endocrinologists


Table 1.1 The spectrum of IDD across the life-span Source: Adapted with permission of the publisher,

from Hetzel (2), Laurberg et al. (3)Stanbury et al. (4).

Fetus Abortions, Stillbirths, Endemic cretinism,

•  Neonate Neonatal goitre, Neonatal hypothyroidism, Endemic •  mental retardation,

•  Child and Goitre, Impaired mental physical development

•  Adolescent

•  Adult Goitre, Hypothyroidism, hyperthyroidism in the elderly, •  Iodine-induced hyperthyroidism


UpToDate Terms of Use©2014 UpToDate, Inc. P. Vitti, DS Ross, JE Mulder , Eds

•  GEOGRAPHIC DISTRIBUTION of IODINE DEFICIENCY

In 2007, data from 130 countries (92.4 % of the world‘s 6 to 12 year

population) showed that:

31.5 % (264 million) of school-aged children (corresponding to about

2 billion of general population individuals) were iodine deficient

•  (This represented a 5 % decrease in prevalence in school-aged

children since 2003.)



Indicator of Iodine Status

Till the end ‘90 Total Goiter Prevalence (TGP) Nowadays the system for classifying iodine deficiency and sufficiency is based upon the median urinary iodine concentration. The most usual survey group is school-age children. -Mild iodine deficiency is defined as a median urinary iodine concentration of 50 to 99 µg/L - Moderate deficiency as 20 to 49 µg/L - Severe deficiency as <20 µg/L


Iodine deficiency in Europe, P. Vitti, F. Delange, A. Pinchera, M. Zimmermann, *J.T. Dunn THE LANCET • Vol 361, 2003

and Iodine deficiency disorders in Europe P Vitti*, T Rago, F Aghini-Lombardi , A Pinchera, Public Health Nutrition: 2001, 4(2B), 529±535

Modest Iodine deficiency (20–49 µg/l), 1 country Mild deficiency (50–99 µg/l), 10 countriesses

Risk of iodine-induced hyperthyroidism (200–299 µg/l), 1 country No data

Optimal (100–199 µg/l), 20 countriesses

No data


Iodine deficiency disorders in Europe, P Vitti*, T Rago, F Aghini-Lombardi , A Pinchera Public Health

Nutrition: 2001, 4(2B), 529±535

•  The existence of goiter in Italy has been known since the age of the ancient Romans.

•  A clear relationship between endemic goiter and endemic cretinism was recognized in 1848 by an `ad hoc' committee appointed by Carlo Alberto the king of Sardinia.

•  Iodine deficiency in endemic areas was first documented in the early 20th century in Piemonte/Valle d'Aosta (A. Costa)

•  e nel Lazio (L. Baschieri) •  In surveys from 1978 and 1991 the goiter prevalence ranged from 14

to 73%


Osservatorio Nazionale per il Monitoraggio della

Iodoprofilassi in Italia (OSNAMI), I.S.S.

•  Circa il 29% della popolazione mondiale è ancora esposto alla carenza di iodio

• 

•  In Italia si stima che più del 10% della popolazione sia affetta da gozzo,

•  con circa 50 ricoveri ogni 100 mila abitanti/anno •  e con un costo economico sul Sistema Sanitario Nazionale di oltre

150 milioni di euro all’anno.


Iodine deficiency in Europe Iodine deficiency disorders, P Vitti*, T Rago, F Aghini-Lombardi , A Pinchera Public

Health Nutrition: 2001, 4(2B), 529±535

•  La manifattura del sale iodato è stata permessa per legge nel 1972 e la distribuzione effettuata, su richiesta, in aree selezionate di endemia gozzigena.

•  Nel 1977 la distribuzione è stata estesa a tutto il Paese

•  e con la legge per la iodioprofilassi del 21 marzo 2005 n. 55 sono state definite le modalita' di utilizzo e di vendita del sale alimentare arricchito con iodio sia destinato al consumo diretto che come ingrediente nella industria alimentare


Osservatorio Nazionale per il Monitoraggio della Iodoprofilassi in Italia (OSNAMI), I.S.S.

•  Solo il 55% della popolazione italiana utilizza sale iodato.

•  La percentuale di vendita di sale iodato:

•  presso la grande distribuzione è di circa il 55% di tutto il sale venduto,

•  nella ristorazione collettiva è del 23% ,

•  e nell’industria alimentare è del 7% (Svizzera 60%)


Prevalence of goitre in examined children adjusted for age and gender. Thyroid Res. 2012;5:23-23.


Daily iodine intake and the impact of salt reduction on iodine prophylaxis in the Italian population- A Pastorelli, P Stacchini and A Olivieri

European Journal of Clinical Nutrition advance online publication, 8 October 2014; doi:10.1038/ejcn.2014.206

•  The aim was (i) to estimate the daily iodine intake in the Italian population, (ii) to verify whether salt intake of 5 g/day in adults and less in children may be sufficient, (iii) to estimate the contribution of iodine-enriched vegetables to the total daily iodine intake (0.3 vs 0.03 µg/g wet mass).

•  Results: The total daily iodine intake owing to food and uniodized salt consumption resulted lower than the daily requirement in all age groups.

•  With a daily consumption of 5 g of salt iodized at 30 mg/kg, the estimated daily iodine intake resulted within the range of optimal iodine intake in all age groups.

•  In children the recommended iodine intake is achieved with a daily consumption of 3 g of iodized salt.

•  Conclusions: …study suggests that the recommended quantities of salt, iodized at 30 mg/kg, are sufficient to achieve the adequate daily iodine intake both in adults and children.


The effect of voluntary iodine prophylaxis in a small rural community: the Pescopagano survey 15 years later.

Aghini Lombardi F et Al J Endocrinol Invest, 2013 May;36(5):282-6.

•  The objective of the study was to verify the effects of voluntary iodine prophylaxis in a small rural community.

•  In 2010, 65.9% subjects routinely used iodized salt, urinary iodine excretion being significantly higher than in 1995.

•  The prevalence of goiter was lower in 2010 than in 1995 (25.8% vs 46.1%,),

•  •  The prevalence of hypothyroidism was higher in 2010 vs 1995 (5.0% vs 2.8%), because of an

increased frequency of subclinical hypothyroidism in subjects younger than 15 years old. •  Serum thyroid autoantibodies and Hashimoto's thyroiditis were more frequent in 2010 than in 1995


PROGETTO ITALIANO CONTRO LA CARENZA IODIO IN PEDIATRIA:SIEDP Genova

24 settembre 2014 •  Secondo i nuovi Livelli di Assunzione Raccomandati di nutrienti

(LARN 2012) il fabbisogno giornaliero di iodio è:

•  nell’adulto di 150 µg (150 µg EFSA: European Food Safety Authority ),

•  •  nel bambino e nell’adolescente è 90-120 µg (70-130 µg EFSA), •  in gravidanza fino a 220 µg al giorno (200 µg EFSA) •  e durante l’allattamento fino a 290 µg (200 µg EFSA);

•  Da ricordare che con la cottura il contenuto di iodio nei cibi si riduce: del 20% con la frittura, del 58% con l’ebollizione, e del 23% con la cottura a vapore. In commercio ci sono formulazioni di sale iodato protetto che non risentono di queste perdite.


L’Apporto ottimale di iodio ”mai lesinare”

Conclusione 1 •  In Italia più del 10% della popolazione è affetto da gozzo

•  Solo il 55% della popolazione italiana utilizza sale iodato, il 23% nella ristorazione collettiva e il 7% nell’industria alimentare (Svizzera 60%)

•  E’ necessario quindi: •  1. aumentare direttamente o indirettamente l’assunzione di iodio

•  2. una Campagna di Informazione e di Educazione che coinvolga la cittadinanza e in particolare il M.M.G. che deve suggerire (o meno) l’assunzione di iodio in base allae predisposizione alle tireopatie di ogni singolo individuo



•  Conclusione 2

•  La Iodoprofilassi è necessaria e va attuata con la migliore modalità per quella popolazione

•  (Salt iodization is safe, largely self-financing and extremely cost-effective, WHO)

•  Con particolare attenzione nelle aree con carenza iodica, nell’età scolare, nelle donne in gravidanza.


13°Congresso Nazionale AME Associazione Medici Endocrinologi

6th Joint Meeting with AACE American Association of Clinical Endocrinologists

•  The secret of a good presentation :

•  to have a good beginning and a good ending;

•  and to have the two as close together •  as possible (best < 10 minutes).


13°Congresso Nazionale AME Associazione Medici Endocrinologi

6th Joint Meeting with AACE American Association of Clinical Endocrinologists

L’Apporto ottimale di iodio ”mai lesinare” (F. Monaco, CH)

anche nei soggetti suscettibili a disfunzioni tiroidee?

(per esempio in Pazienti con autonomia tiroidea, nella tiroidite cronica autoimmune, nell’anziano ?)

vs “con qualche attenzione” (S. Corsello (RM)


Scientific Opinion on Dietary Reference Values for iodine1

EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA)2,3 European Food Safety Authority (EFSA), Parma, Italy

EFSA Journal 2014;12(5):3660 •  Panel members EFSA:

•  Carlo Agostoni (60), Roberto Berni Canani (1), Susan Fairweather-Tait (82), Marina Heinonen (36), Hannu Korhonen (20), Sébastien La Vieille (11), Rosangela Marchelli (79), Ambroise Martin (8), Androniki Naska (70), Conia Neuhäuser-Berthold (0), Grażyna Nowicka (23), Yolanda Sanz (84), Alfonso Siani (48), Anders Sjödin (26), Martin Stern (96), Sean (J.J.) Strain (0), Inge Tetens (83), Daniel Tomé (177), Dominique Turck (88) and Hans Verhagen (29).

•  Pubblicazioni: su Nutrimenti, Diabete, Fibrosi cistica, Down s.. Nessun articolo su Tiroide

•  World status of monitoring iodine deficiency disorders control programs. Delange F, Burgi H, Chen ZT, Dunn JT. Thyroid , 2002 Oct;12(10):915-24.


•  PREDICTING PHYSIOLOGICAL EFFECTS OF NONPRESCRIPTION (OTC) THYROID SUPPLEMENTS: CAVEAT EMPTOR J. Di Stefano, S. Han, M. Eisenberg, P. Larsen, UCLA, CA;

•  Epidemiology & Mathematics, University of Michigan, Ann Arbor, MI; 3Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA

• 

•  …thyroid hormone content in readily available ‘‘thyroid supportive’’ health supplements was reported in Thyroid 2013. Some contained clinically relevant amounts of T4 and T3. These amounts ‘‘potentially expose patients to the risk of thyroid level alterations, even to the point of developing iatrogenic thyrotoxicosis’’higher T4 dose levels.

•  …the amounts of Thyroid hormones in certain preparations can cause thyrotoxicity, with adverse effects on bone and heart. These simulations provide support for restrictions on their unregulated availability.

•  Enriched vegetable 0.3 µg/g


A.T.A 2014. IODINE STATUS IN KOREAN HEALTHY PREGNANT WOMEN: A FIRST REPORT D. Jeong, Y. Cho, J. Joung, S. Sohn, S. Lee, S. Oh, C. Roh, J. Chun1, S. Kim ,Endocrinology & Metabolism, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea

•  Proper iodine intake is important during pregnancy for both fetal neurodevelopment and maternal thyroid function. Korea is known as high iodine intake area. Urine iodine concentration was evaluated in pregnant women.

•  Only 13.7% of subjects were in adequate range of iodine nutrition based on WHO criteria. 65.1% consumed iodine exceeding above requirements whereas, 21.2% were categorized as insufficient in iodine intake.

•  ……….. the median UIC was 422.3 lg/L. Considering highly variable range of iodine intake, active education about proper iodine intake for the pregnant women in iodine excessive area is necessary.

•  URINARY IODINE EXCRETION AND SERUM THYROID FUNCTION IN HEALTHY ADULTS AFTER IODINATED CONTRAST ADMINISTRATION S.Y. Lee, D.L. Chang, X. He, E.N. Pearce, L.E. Braverman, A.M. Leung, Boston University School of Medicine, MA; Division of Endocrinology, VA Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Endocrinology, Reliant Medical Group, Worcester, MA

•  •  1 hyperthyroidism and 12 hypothyroidism •  As thyroid dysfunction developed in 15% following a single ICM dose, monitoring of

thyroid function should be considered in at-risk patients. • 

• 


SALE IODATO:

dove c'è e quanto costa (aprile 2011) AltroCONSUMO

Supermercati, ipermercati e Hard Discount

•  Città Presenza Prezzi min - max in euro Prezzi del sale comune min - max

•  del sale iodato

•  MILANO sempre presente 0,11 - 1,09 0,11 - 0,86

•  ROMA sempre presente 0,39 - 0,79 0,11 - 0,79

•  BARI sempre presente 0,11 - 1 0,11 - 0,40

•  PALERMO sempre presente 0,41 - 1,09 0,11 - 0,8

•  Tabaccai, drogherie, piccoli alimentari

•  MILANO no in 7 su 10 0,80 - 1,20 0,60 - 1

•  ROMA no in 7 su 10 0,65 - 1 0,18 - 1

•  BARI sempre presente 0,50 - 1,20 0,30 - 0,90

•  PALERMO no in 1 su 7 0,30 - 0,80 0,11 - 0,60

•  Il sale iodato, strumento fondamentale di prevenzione di alcuni disturbi importanti, è spesso molto più caro del normale sale da cucina. E non sempre si trova. La nostra indagine in 4 città (AltroCONSUMO) il sale iodato costa il doppio di quello comune: 53 centesimi di euro al chilo contro 30 centesimi. (per alcuni produttori prezzo >5,00 Euro Kg)



•  Ma

•  Nei soggetti suscettibili a disfunzioni tiroidee? (per esempio in Pazienti con autonomia

tiroidea, nella tiroidite cronica autoimmune, nell’anziano ?)


LEGGE 21 marzo 2005, n. 55 Disposizioni finalizzate alla prevenzione del gozzo endemico e di

altre patologie da carenza iodica. •  Art. 3

•  Sale destinato al consumo diretto •  •  1. I punti vendita di sale destinato al consumo diretto assicurano la contemporanea disponibilità di sale

arricchito con iodio e di sale alimentare comune; quest'ultimo è fornito solo su specifica richiesta del consumatore.

•  2. Nell'ambito della ristorazione pubblica, quali bar e ristoranti e di quella collettiva, quali mense e comunità, è messo a disposizione dei consumatori anche il sale arricchito con iodio.

•  3. Negli espositori dei punti vendita di sale alimentare è apposta una locandina diretta ad informare la popolazione sui principi e sugli effetti della iodioprofilassi, individuata con decreto del Ministro della salute.

•  Art. 4 •  Sale impiegato come ingrediente nella preparazione e nella conservazione dei prodotti alimentari •  1. È consentito anche l'impiego del sale arricchito con iodio quale ingrediente nella preparazione e nella

conservazione dei prodotti alimentari. •  Art. 6

•  Pubblicità •  1. Allo scopo di promuovere forme di pubblicità caratterizzate da un elevato contenuto informativo, il

Ministero della salute può concedere il proprio patrocinio non oneroso ai messaggi pubblicitari del tipo di sale di cui all'articolo 2, comma 2, al fine di promuovere una migliore e più completa informazione in ordine ai disturbi provocati da carenza iodica ed ai benefici di una profilassi basata sull'impiego di sale addizionato di iodio.


Iodine deficiency in Italy Iodine deficiency disorders in Europe, P Vitti*, T Rago, F Aghini-Lombardi , A Pinchera

Public Health Nutrition: 2001, 4(2B), 529±535

•  Data from single epidemiological surveys carried out in the years 1978±1991 in a total number of 72.112 schoolchildren (6±14 years) examined, including 5046 controls residing in urban and extra-urban endemic areas throughout Italy

•  showed : •  •  Mean UIE between 50 and 75 vs from 85 to 175 µg/g of creatinine in control areas.

•  The prevalence of goiter in schoolchildren of endemic areas ranged from 14% to 73%, inversely correlated with iodine excretion vs below 10% in the control areas.

•  •  Goiter prevalence was greater in Central and Southern Italy.

•  (In some areas with moderate or severe iodine deficiency cases of cretinism and mental defects were found. Minor neuro-psycological impairments were detected in schoolchildren residing in moderate iodine deficiency.)


Iodine deficiency in Italy Iodine deficiency disorders in Europe, P Vitti*, T Rago, F Aghini-Lombardi , A Pinchera Public

Health Nutrition: 2001, 4(2B), 529±535

The conclusion of this study was that: in an iodine deficient community a progressive increase of goiter prevalence occurred with age with a high proportion of nodularity and functional autonomy in the adult population. Hyperthyroidism was twice as high than that reported in iodine sufficient areas, the difference being mainly due to an increased frequency of toxic nodular goiter, while the prevalence of hypothyroidism and thyroid cancer showed no difference. Serum TgAb and TPOAb were more frequently detectable with respect to iodine sufficient areas, while the prevalence and age distribution of diffuse autoimmune thyroiditis was relatively low.


Sufficient Likely sufficient Deficient Likely deficient >100 µg/L <100 µg/L Austria Iceland Belgium Albania Bosnia Luxembourg Denmark Bulgaria Norway France Croatia Sweden Germany Cyprus Greece Czech Republic Hungary

Finland Italy Macedonia Ireland Netherlands Montenegro Poland Romania Portugal Slovenia Slovak Republic Spain Serbia Turkey Switzerland UK

Iodine nutrition status by country, based on urinary iodine excretion (µg/L)

Vitti, Delange, Pinchera, Zimmerman, Dunn The Lancet 361, 2003


Campagna Sociale di Informazione e di Educazione alla Salute Infantile: Progetto Italiano Contro la Carenza di Iodio in

Pediatria, SIEDP, Genova 23 IX 2014

•  È stata determinata la ioduria su campioni estemporanei di urine di bambini in età scolare reclutati dagli Osservatori Regionali per la Prevenzione del Gozzo (Legge n. 55/2005).

•  I dati degli ultimi tre anni hanno mostrato che in 6 delle 9 Regioni che hanno partecipato allo studio i valori mediani di ioduria rilevati sono ancora al di sotto di 100 µg/L valore indicato dalla World Health Organization (WHO) come soglia al di sotto della quale la popolazione esaminata viene identificata come iodocarente.

•  In sole 3 Regioni (Sicilia, Toscana, Liguria) stati rilevati valori indicativi di uno stato di iodosufficienza.

•  In 5 Regioni è stata determinata la ioduria in donne in gravidanza che non assumevano integratori contenenti iodio.

•  I risultati dimostrano una condizione di insufficiente apporto iodico in tutte e 5 le Regioni, confermando la necessità dell’integrazione iodica in gravidanza e durante l’allattamento.


Campagna Sociale di Informazione e di Educazione alla Salute Infantile: Progetto Italiano Contro la Carenza di Iodio in

Pediatria, SIEDP, Genova 23 IX 2014

•  L’iniziativa prevede l’organizzazione, da ottobre 2014 a •  maggio 2015, di dieci incontri educazionali in alcune •  scuole primarie e dell’infanzia delle città di Genova, •  Torino, Milano, Bologna, Pisa, Roma, Napoli, Potenza, •  Bari e Cagliari.

•  Sono, inoltre, in programma incontri •  formativi per la categoria medica.


Campagna di Informazione e di Educazione alla Salute Infantile trasversale, che coinvolga quindi sia la cittadinanza,

a partire dalle giovani donne, che la classe medica.

Gli incontri educazionali nelle scuole L’informazione alla classe medica

Le Associazioni dei Pazienti e le Istituzioni scientifiche Supermercati

Mezzi di informazione

PROGETTO ITALIANO CONTRO LA CARENZA IODIO IN PEDIATRIA: SIEDP 24 settembre 2014



The World Health Organization (WHO) recommends: - 90 µg of iodine daily for infants and children up to five years (40 µg for newborn), - 120 µg for children 6 to 12 years, 150 µg daily for children ≥12 years and adults, - 250 µg and 290 µg daily respectively during pregnancy and lactation. The United States Institute of Medicine (IOM) recommended minimum daily intake of iodine is similar: 90 µg daily for children one to eight years old, 120 µg for children 9 to 13 years, 150 µg daily for older adolescents and non-pregnant adults, 220 µg for pregnant women, and 290 µg for lactating women.


Salt as a Vehicle for Fortification Report of a WHO Expert Consultation Luxembourg21-22 March 2007

Recommendations:

•  National policies should commit to reducing the average salt consumption of the adult population to <5 g/day, …….

•  The prevention of IDD is possible by increasing dietary iodine intake. Salt is the most widely used vehicle for iodine fortification.

•  Policies for salt iodization and reduction of salt to <5 g/day are compatible, cost effective and of great public health benefit.

•  Reliance on salt as a vehicle for the delivery of dietary iodine should not be used to justify promotion of salt intake to the public.

•  The current recommendation that salt be fortified with iodine at a level of 20-40 ppm is based on the assumption of an average salt intake of 10 g/day at the population level. This assumption may no longer be valid because salt intake in populations may vary substantially…..

•  The level of iodine fortification needs to be adjusted by national authorities responsible for the implementation and monitoring of USI

•  The iodine concentration in salt should be determined considering both the level of salt consumption and median UI of the population.

•  Ministries of health should ensure that health promotion messages do not inadvertently promote excessive salt consumption.

•  Lessons from successful experiences in countries that have implemented both reduction of salt consumption and salt iodization policies should be considered when ministries of health plan to implement these policies.

•  Advocacy from International Organizations (e.g. WHO, UNICEF, FAO), NGO’s and academia with policy makers is recommended in order to promote the development and implementation of policies that aim both at safe salt iodization and effective reduction in salt intake.

•  Food fortification, including salt iodization, should be appropriately regulated by governments

•  Multinational food industries are encouraged to harmonize the salt content of their products according to the lowest threshold possible to avoid unnecessary variations in salt content of the same food product commercialized in different countries.

•  •


Table 2.1 Epidemiological criteria for assessing iodine nutrition based on median UI concentrations

Iodine intake Iodine nutrition Pregnant women UI/µg/L

<150 Insufficient 150–249 Adequate 250–499 More than adequate >500a Excessive

Lactating womenb

<100 Insufficient >220-290b Adequate

Children less than 2 yr of age <100 Insufficient >100 Adequate A median average daily iodine intake of 150 µg corresponds to a median urinary iodine concentration of 100 µg/L a The term excessive means in excess of the amount needed to prevent and control iodine deficiency. b In lactating women, the numbers for median UI are lower than the iodine requirements because of the I excreted in breast milk.


Table 2.1 Epidemiological criteria for assessing iodine nutrition based on median UI concentrations

•  School-age children

•  Median UI (µg/l) Iodine intake Iodine nutrition

•  < 20 Insufficient Severe iodine deficiency •  20–49 Insufficient Moderate iodine deficiency •  50–99 Insufficient Mild iodine deficiency •  100–199 Adequate Optimal iodine nutrition •  200–299 More than adequate Risk of iodine-induced

hyperthyroidism with 5–10

years •  following introduction of iodized •  salt in susceptible groups •  ≥ 300 Excessive Risk iodine induced •  hyperthyroidism and •  auto-immune thyroid diseases •  Source: WHO et al. (12). • 


The size of the community rather than its geographical location better defines the risk of iodine deficiency: results of an extensive survey in

Southern Italy. Aghini-Lombardi F et Al

•  Results:

•  1) in Southern Italy mild to moderate iodine deficiency is still present;

•  •  2) median UIE in non urban areas is lower than in urban areas and

is related to the size of the community rather than to its geographical location, being higher in a larger community.

•  This may be due to better diversification of dietary habits and the easier availability of iodized salt and processed food through commercial facilities, more common in larger communities.


Prevalence of goitre in examined children adjusted for body surface area (BSA) and gender. Thyroid Res. 2012;5:23-23.

L’Apporto ottimale di iodio · Aghini Lombardi F et Al J Endocrinol Invest, 2013 May;36(5):282-6....

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