Urinary iodine concentration during pregnancy in an area of unstable dietary iodine intake in Switzerland.

We prospectively investigated urinary iodine concentration (UIC) in pregnant women and in female, non-pregnant controls in the canton of Berne, Switzerland, in 1992. Mean UIC of pregnant women [205 +/- 151 microg iodine/g creatinine (microg l/g Cr); no. = 153] steadily decreased from the first (236 +/- 180 microg l/g Cr; no. = 31) to the third trimester (183 +/- 111 microg l/g Cr, p < 0.0001; no. = 66) and differed significantly from that of the control group (91 +/- 37 microg l/g Cr, p < 0.0001; no. = 119). UIC increased 2.6-fold from levels indicating mild iodine deficiency in controls to the first trimester, demonstrating that high UIC during early gestation does not necessarily reflect a sufficient iodine supply to the overall population. Pregnancy is accompanied by important alterations in the regulation of thyroid function and iodine metabolism. Increased renal iodine clearance during pregnancy may explain increased UIC during early gestation, whereas increased thyroidal iodine clearance as well as the iodine shift from the maternal circulation to the growing fetal-placental unit, which both tend to lower the circulating serum levels of inorganic iodide, probably are the causes of the continuous decrease of UIC over the course of pregnancy. Mean UIC in our control group, as well as in one parallel and several consecutive investigations in the same region in the 1990s, was found to be below the actually recommended threshold, indicating a new tendency towards mild to moderate iodine deficiency. As salt is the main source of dietary iodine in Switzerland, its iodine concentration was therefore increased nationwide in 1998 for the fourth time, following increases in 1922, 1965 and 1980.

Judgment analysis in clinical nephrology.

To ameliorate the clinical performance of nephrologists, improving their clinical judgment is crucial. No methodology for judgment analysis in nephrology is currently available. Therefore, we designed a trial to assess the intraphysician consistency of the judgment of typical non-end-stage renal disease (ESRD) patients by 24 board-certified nephrologists. The participants were asked to analyze cases to determine the interobserver variability with respect to diagnosis, therapy, prognosis, and strategy of follow-up. They were unaware that every patient was presented on 2 occasions separated by a period of 6 months. Of the 1,288 questionnaires that were completed, 28 cases belonged to 1 of the following 3 groups: (A) patients once with, once without renal histology, (B) patients twice without histology, and (C) patients twice with histology. Only cases of group (A) differed at the 2 occasions of assessment with respect to knowledge of histology. The results from the first and second assessment were compared and analyzed. The median (95% confidence interval) percentages of changed diagnoses were 64% (59% to 68%), 50% (44% to 62%), and 33% (26% to 47%) in groups A, B, and C, respectively, indicating large intraobserver variability. The frequency of changes in diagnoses declined with the degree of confidence in the first diagnosis in all 3 groups. The subjective desire to know the histology was without impact on the frequency of changes in diagnoses. However, a knowledge of the histology enhanced the degree of confidence in the diagnoses. Interestingly, the enormous variability in changing diagnoses from one analysis to the other was not reflected by corresponding changes in the judgment of prognosis, therapy to be prescribed, or strategy of follow-up. The individual judgment with respect to diagnosis of clinical cases is inconsistent and highly dependent on the subjective degree of confidence in the diagnosis. The practical relevant consequences traditionally derived from a diagnosis (therapy, prognosis, and strategy of follow-up) are only marginally, if at all, affected by changing the diagnosis. Thus, the utility of "diagnosis" for judgment analysis in clinical nephrology should be reconsidered.

[How great is the risk of cancer and recurrence following benign breast biopsy?]. / Wie gross ist das Karzinom- und Rezidivrisiko nach gutartiger Mammabiopsie?

Four hundred and thirty-eight patients with biopsy-proven benign breast disease were followed annually in a prospective manner for 4-17 years, to analyze breast cancer risk, correlations with cancer development and recurrence during follow-up. Twelve breast cancers developed in 12 patients during follow-up, giving a 2.6 fold increased cancer risk over the reference population. No association was found between patients who developed cancer and those who did not with respect to the initial histologic feature (p = 0.9), the age at entry by decades (p = 0.4) and relative to menopause (p = 0.3), the presence of cysts (p = 0.5) or calcification (p = 0.2) in the biopsy specimen, a family history of breast cancer (p = 0.7) or the follow-up time (p = 0.9). Benign breast disease does not inevitably lead to recurrence. Moreover, 47% of the 438 patients never had any recurrence and were free of symptoms during follow-up, and 84% never required a further operation. We conclude that an aggressive approach to benign breast disease is not justified, for any type of lesion as defined in this report.

Long-term follow-up of patients with biopsy-proven benign breast disease.

Three hundred sixty-five patients with biopsy-proven benign breast disease were followed annually in a prospective manner for 4-15 years to analyze breast cancer development, recurrence, and efficacy of management during follow-up. Eleven breast cancers developed in 11 patients during follow-up, giving a 2.6-fold increased cancer risk over the reference population. No association was found between patients who developed cancer and those who did not with respect to the initial histologic feature (p = 0.62), the age at entry by decades (p = 0.40), and relative to menopause (p = 0.54), the presence of cysts (p = 0.87), or calcification (p = 0.74) in the biopsy specimen, a family history of breast cancer (p = 0.80), or the number of observation years (p = 0.27). We conclude that an aggressive approach to benign breast disease is not justified for any type of lesion as defined in this report. Benign breast disease does not inevitably lead to recurrence. Moreover, 41% of our patients never had any recurrence and were free of symptoms during follow-up; 67% never had a mammogram and 82% never required a further operation. There was no association with initial histologic feature in patients who had clinical examination only and those who had mammogram, biopsy, or both during follow-up (p = 0.93). Mammograms were mainly used to clarify a clinical recurrence than as a screening tool, regardless of histologic feature (p = 0.76). Mammograms were mainly used in premenopausal patients (p less than 0.001) having lumps (p less than 0.001), namely, the most difficult patients for radiologic interpretation. This may be one important reason for the rather low sensitivity (75%) and specificity (40%) of mammography in this report. In conclusion, clinical examination is the outstanding investigational tool to follow patients with biopsy-proven benign breast disease, especially in young premenopausal patients.