454

each senior registrar post both in and outside the NHS. If the cosmetic content is inadequate the post will not be recognised for

training. BAAPS was founded in 1977 and is affiliated to the British Association of Plastic Surgeons (BAPS) at the Royal College of Surgeons (RCS). Its sole pupose, as defmed in our published constitution, is "the advancement of education in and practice of aesthetic plastic surgery for the public benefit". The memorandum and articles of this association are available to anyone on application (as required by law), but our membership list, at present, is available only co medical practitioners. The rules governing membership are: (1) full accreditation in plastic surgery by the RCS (which includes cosmetic surgery); (2) a log-book of cosmetic surgical procedures undertaken with or without help; (3) knowledge of defmed publications in cosmetic surgery; (4) attendance at at least four national or international meetings on cosmetic surgery; (5) satisfaction of the educational subcommittee that these criteria have been met; and (6) recommendation by two full members that candidates have satisfied these criteria. Membership is voluntary, but we have 120 members and associates throughout the UK and Eire. The required syllabus for cosmetic surgery training is published and is available from the BAAPS office at the RCS. By contrast, the only requirement for membership of the British Association of Cosmetic Surgeons (BACS), according to Skanderowicz, is fellowship of the RCS, which is an entry exam to higher surgical training. In 1990, the BACS membership list was freely available to the general public, even though this was contrary to existing GMC guidelines. It consisted of about twelve members and a few overseas members and contained no mention of any training programme. The late Sir Alan Parks, past president of the English Royal College of Surgeons, said that the presidents of all the Royal Colleges agreed that training in plastic surgery was the correct programme for training in cosmetic surgery. This view has been endorsed lately by a joint meeting of the Royal Colleges who noted that aesthetic surgery should be recognised as a distinct subspecialty of plastic surgery. Skanderowicz should provide details of all the entry qualifications for BACS; of how BACS has promoted the highest standards of surgery in the past 10 years; of what new procedures BACS has introduced; and of how BACS has protected the public from unskilled pracritioners. As past secretary and president of BAAPS, I am aware of wrongful suggestions that plastic surgeons are not trained in cosmetic surgery. It is incorrect that plastic surgeons claim they are the only surgeons who are trained and adept at these procedures. 1991 BAAPS membership book (p 4) states "... The British Association of Aesthetic Plastic Surgeons do not claim to be the only surgeons practising Aesthetic Surgery but the qualifications required for entry onto this list are made clear in our published constitution ...". St Thomas’ Hospital, London SE1 7EH, UK

Serum levels of fT4 (8) and hTSH with choriocarcinoma.

Physiological levels (mean+3SD,

SiR,—The possibility thyrotropin (TSH)-like activity of human chorionic gonadotropin (hCG) has long been debated. Although intrinsic TSH-like activity of hCG (less than 1 % of that of genuine hTSH) can be demonstrated in vitro in terms of receptor binding and target cell response, clinical signs of hyperthyroidism are rare in pregnancyl-3 and gestational trophoblastic diseases’ when hCG levels are high. We have monitored thyroid status in eight patients with testicular tumours over 6 months to a year. On 82 sera we measured hCG, free thyroxine (f 1’4), and hTSH. The testicular tumours of each of these patients secreted huge amounts of hCG (up to 500 tig/m! serum). Under chemotherapy hCG levels fell sharply in all patients, and in four returned to normal (below 240 pg/ml, corresponding to about 2 IUjl5). Although hCG in pretreaunent sera exceeded peak pregnancy levels 20-50-fold, no sign of hyperthyroidism was detected: fT4 levels remained normal at 37-17 pg/ml, hTSH levels

eight male patients

99 7% confidence

limit) indicated

also normal (0 02-66 IU/mI); and neither in longitudinal on individual patients nor in the pooled data was there a correlation between million-fold changing levels of hCG and fl’4 or hTSH (figure). This makes tumour-derived hCG unlikely as a direct in-vivo thyroid stimulator. The in-vitro TSH-like activity of hCG can best be explained by cross-reactivity with respect to receptor binding. For some unknown reason this quality seems not to manifest in vivo. In those rare cases where hyperthyroidism is observed it may be associated with non-hCG-related characteristics of tumour itself or be fortuitous since about 1 % of patients admiued to hospital may present with thyroid hyperfunction.1

profiles

Institute for Biomedical Aging Research of Austrian Academy of Sciences, A-6020 Innsbruck, Austria

Department of

P. BERGER S. MADERSBACHER

Internal Medicine II,

Klinikum Grosshadern, University of Munich,

Munich, Germany

K. MANN

Institute for General and Experimental Pathology, University of Innsbruck

S. SCHWARZ G. WICK

1. Pekonen F, Alfthan H, Stenman U-H, Ylikorkala O. Human chononic gonadotropin and thyroid function in early human pregnancy: circadian variation and evidence for intrinsic thyrotropic activity of hCG. J Clin Endocrinol Metab 1988; 66: 853-56. 2 Yoshikawa N, Nishikawa M, Horimoto M, et al. Thyroid-stimulating activity in sera of normal pregnant women. J Clin Endocrinol Metab 1989, 69:891-95. 3 Bellabio M, Sinha A, Ekins R. Thyrotropic activity of crude hCG in FRTL-5 rat thyroid cells. Acta Endocrinol 1987; 116: 479-88 4. Mann K, Schneider N, Hoermann R. Thyrotropic activity of acidic isoelectric variants of human chononic gonadotropin from trophoblastic tumors. Endocrinology 1986; 118: 1558-66 5. Madersbacher S, Berger P, Mann K, Kuzmists R, Wick G. Diagnostic value of free subunits of serum chorionic gonadotropin in testicular cancer. Lancet 1990; 336: 630-31. 6. Nicoloff JT, Spencer CA Clinical review 12 the use and misuse of the sensitive thyrotropin assays J Clin Endocrinol Metab 1990; 71: 553-58.

Thyroid-associated eye disease

Does tumour-derived hCG stimulate

thyroid?

in

were

P. K. B. DAVIS

of

(U)

p

SiR,—Professor Weetman (July 6, p 25) and Mr Fells (July 6, 29) have clarified the notion of thyroid-associated eye disease in

their comprehensive review of pathophysiology and clinical management. I would draw attention to the clinical triad of exophthalmic ophthalmoplegia, gross clubbing of the fingers and toes (thyroid acropachy), and pretibial myxoedema, which I reviewed in 1958.1I suggested that this clinical association in thyrotoxic patients who had become euthyroid or hypothyroid with medical, surgical, or radioiodine treatment might not be as rare as the lack of published reports suggests. ’I’his view was later endorsed by Gimlette in his papers on thyroid acropachy and pretibial myxoedema.2,3 It was noteworthy that one of my patients with previously untreated thyrotoxicosis also showed this clinical triad. In drawing attention to the role of the pituitary gland in the pathogenesis of thyroid-associated eye disease, I emphasised that necropsy findings in two patients who I reviewed showed evidence of pituitary dysfunction. One patient had an eosinophil adenoma of the pituitary gland; the other had eosinophil hyperplasia of the

Does tumour-derived hCG stimulate thyroid?

454 each senior registrar post both in and outside the NHS. If the cosmetic content is inadequate the post will not be recognised for training. BAAP...
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