1350
being recurrently embarrassed when our remuneration is publicly discussed; but at least the Review Body has removed much of the public haggling which used to take place, and the independent Review Body is supposed to give the profession what it deserves. I suspect that Lefever’s reaction to general practice is due to the "mass of trivia" which makes some G.P.s so unhappy; but it is only at the end of the consultation that one can classify the triviality of an illness. Perhaps patients with cancer or myocardial infarction should be treated in hospital, but how will they get there? Someone, sometime has to decide. The Western World has decided, I believe rightly, that first contact should be with a doctor, and if primary contact with a doctor is right for the rich and private patient, then this is what should apply in the National Health Service. I am surprised that some more senior G.P. has not replied to Professor Jennett’s thesis that a superior specialist should have someone between him and the family doctor (March 17, p. 594). Does he too feel so overwhelmed by a mass of trivia that some barrier should be erected? Sir James McKenzie waded through a mass of trivia in Burnley, and became a founding father of cardiology and good general practice. Lefever undoubtedly could promote the health of his obese patients with their trivial complaint by improving his 10-year cure-rate for obesity, which I suspect is poorer than that for malignant cerebral tumours in Jennett’s unit; and one of the recurring problems of general, and no doubt neurosurgical, practice is the trivial question "When is a headache a headache and not a cerebral tumour"? Unfortunately the truly general physician is largely a thing of the past, now that most physicians have their special interests. It is probably true to say that 10% of practising doctors in general practice and hospital are excellent, 10% are poor, and the other 80% are hard working and willing to learn; this major group in general practice should surely be the area where centres of excellence should be working to educate the primary-care doctor to fill the role left by the demise of the general physician. And "welfare" may not be part of scientific health care, but it most certainly is part of the compassion which ought to be a feature of medical practice. Lefever’s May 26 article immediately followed one by Professor Kessel on reassurance. Patients go to G.P.S for reassurance ; and are referred to specialists so that both patient and G.P. can have reassurance. These results would be more difficult to achieve if further layers were to be interposed in the nresent structure.
Pedwell
Way, Norham, Berwick upon Tweed, Northumberland
G. A. C. BINNIE
MANIPULATION, OSTEOPATHY, AND BACK PAIN
SIR,-Dr Robertson, president of the British Association of Medical Manipulation, (June 2, p. 1190) fails to understand the recommendations of the Working Group on Back Pain, chaired by Prof. A. L. Cochrane. Robertson says: "there is no need to go outside the medical profession to evaluate manipulative medicine". In this he may well be right, since nobody outside the medical profession would want to claim that he or she is practising "manipulative medicine". The Working Group on Back Pain recognised, however, that many patients do go outside the medical profession for treatment, and they claim to derive benefit from the services of osteopaths, chiropractors, and others. The working party rightly took the view that it is first necessary to test whether such practitioners really do offer effective treatment. If they do, then is the time to assess the nature of this therapy and whether it can or should be equated with manipulative medicine. Much of osteopathy, incidentally, does not fit into the medical definition of manipulation, and to imply, as Robertson
does, that heterodox practices such as osteopathy and chiropractice are to be equated with "manipulative medicine" is indefensible. Whereas the established puncture professions have
osteopathic, chiropractic, and acuagreed to cooperate in setting up comparative trials-although, in contradistinction to their patients, they have nothing whatever to gain from working with doctors inside or outside the National Health Serviceinterested groups within medicine already seem to wish to close ranks to deny the public the opportunity to get at the answers to those fundamental questions which the working-group has realised must be answered before there can be any hope of improving the service to the many back-pain sufferers with whom the medical profession on its own cannot cope. General Council and 16 Buckingham Gate, London SW1.
Register
of Osteopaths,
C. I. DOVE Registrar
AMIODARONE AND THE THYROID
SIR, : Your editorial ot March 17 (p. 599) and Dr Chung’ss letter (April 7, p. 785) refer to the question of thyroid function in patients on amiodarone therapy. The setting-up of specific and direct micromethods for radioimmunoassay of free fractions of thyroid hormones’ permits a more thorough study. We have investigated an 8-year-old boy (weight 22 kg) who since 1974 had had attacks of paroxysmal reciprocating tachycardia due to anomalous retrograde conduction in the atrioventricular node. Several antiarrhythmic drugs had had no effect; only amiodarone 200 mg daily, taken with digitalis, beginning 18 months previously had had good clinical results. After 15 months, however, arrhythmic attacks returned at increasing frequency. Withdrawal of amiodarone reversed the negative symptoms. The data shown in the table refer to the last three months of therapy and to the month after withdrawal of the drug. The main results are the constant decrease in total T3 and free T 3’ an increase in total T4 and in free T4, an increase in reverse T3, and no variation in T.B.G. and T.S.H. After the patient had been off the drug for a month all values had returned to normal. The increase in free T4 may have been responsible for the recurring arrhythmic attacks and for slight clinical symptoms of hyperthyroidism. In view of the conflicting results of previous data, which point to a "low T syndrome"3 we would stress that only with direct and accurate measurement of free fractions were we able to account for the changes induced by amiodarone. Institute
of Radiology, University of Ferrara, 44100 Ferrara, Italy Division of
Cardiology,
Arcispedale "S.
Anna", Ferrara
Dow-Lepetit, Milan
ADRIANO PIFFANELLI DARIO PELIZZOLA LUCIANO RICCI
LUCIANO CODECÁ ANTONIO MASONI PIER BRUNO ROMELLI
1. 2.
Pennisi, F., Romelli, P. B., Vanchieri, L. J. endocr. Invest. 1979, 2, 25. Burger, A., and others J. clin. Invest. 1978, 58, 255. 3. Jonckheer, M. H., and others. Clin. Endocr. 1978, 9, 27.
(SEPT., OCT., NOV.) AND AFTER ITS WITHDRAWAL (DEC.)
THYROID FUNCTION UNDER AMIODARONE THERAPY
being recurrently embarrassed when our remuneration is publicly discussed; but at least the Review Body has removed much of the public haggling which used to take place, and the independent Review Body is supposed to give the profession what it deserves. I suspect that Lefever’s reaction to general practice is due to the "mass of trivia" which makes some G.P.s so unhappy; but it is only at the end of the consultation that one can classify the triviality of an illness. Perhaps patients with cancer or myocardial infarction should be treated in hospital, but how will they get there? Someone, sometime has to decide. The Western World has decided, I believe rightly, that first contact should be with a doctor, and if primary contact with a doctor is right for the rich and private patient, then this is what should apply in the National Health Service. I am surprised that some more senior G.P. has not replied to Professor Jennett’s thesis that a superior specialist should have someone between him and the family doctor (March 17, p. 594). Does he too feel so overwhelmed by a mass of trivia that some barrier should be erected? Sir James McKenzie waded through a mass of trivia in Burnley, and became a founding father of cardiology and good general practice. Lefever undoubtedly could promote the health of his obese patients with their trivial complaint by improving his 10-year cure-rate for obesity, which I suspect is poorer than that for malignant cerebral tumours in Jennett’s unit; and one of the recurring problems of general, and no doubt neurosurgical, practice is the trivial question "When is a headache a headache and not a cerebral tumour"? Unfortunately the truly general physician is largely a thing of the past, now that most physicians have their special interests. It is probably true to say that 10% of practising doctors in general practice and hospital are excellent, 10% are poor, and the other 80% are hard working and willing to learn; this major group in general practice should surely be the area where centres of excellence should be working to educate the primary-care doctor to fill the role left by the demise of the general physician. And "welfare" may not be part of scientific health care, but it most certainly is part of the compassion which ought to be a feature of medical practice. Lefever’s May 26 article immediately followed one by Professor Kessel on reassurance. Patients go to G.P.S for reassurance ; and are referred to specialists so that both patient and G.P. can have reassurance. These results would be more difficult to achieve if further layers were to be interposed in the nresent structure.
Pedwell
Way, Norham, Berwick upon Tweed, Northumberland
G. A. C. BINNIE
MANIPULATION, OSTEOPATHY, AND BACK PAIN
SIR,-Dr Robertson, president of the British Association of Medical Manipulation, (June 2, p. 1190) fails to understand the recommendations of the Working Group on Back Pain, chaired by Prof. A. L. Cochrane. Robertson says: "there is no need to go outside the medical profession to evaluate manipulative medicine". In this he may well be right, since nobody outside the medical profession would want to claim that he or she is practising "manipulative medicine". The Working Group on Back Pain recognised, however, that many patients do go outside the medical profession for treatment, and they claim to derive benefit from the services of osteopaths, chiropractors, and others. The working party rightly took the view that it is first necessary to test whether such practitioners really do offer effective treatment. If they do, then is the time to assess the nature of this therapy and whether it can or should be equated with manipulative medicine. Much of osteopathy, incidentally, does not fit into the medical definition of manipulation, and to imply, as Robertson
does, that heterodox practices such as osteopathy and chiropractice are to be equated with "manipulative medicine" is indefensible. Whereas the established puncture professions have
osteopathic, chiropractic, and acuagreed to cooperate in setting up comparative trials-although, in contradistinction to their patients, they have nothing whatever to gain from working with doctors inside or outside the National Health Serviceinterested groups within medicine already seem to wish to close ranks to deny the public the opportunity to get at the answers to those fundamental questions which the working-group has realised must be answered before there can be any hope of improving the service to the many back-pain sufferers with whom the medical profession on its own cannot cope. General Council and 16 Buckingham Gate, London SW1.
Register
of Osteopaths,
C. I. DOVE Registrar
AMIODARONE AND THE THYROID
SIR, : Your editorial ot March 17 (p. 599) and Dr Chung’ss letter (April 7, p. 785) refer to the question of thyroid function in patients on amiodarone therapy. The setting-up of specific and direct micromethods for radioimmunoassay of free fractions of thyroid hormones’ permits a more thorough study. We have investigated an 8-year-old boy (weight 22 kg) who since 1974 had had attacks of paroxysmal reciprocating tachycardia due to anomalous retrograde conduction in the atrioventricular node. Several antiarrhythmic drugs had had no effect; only amiodarone 200 mg daily, taken with digitalis, beginning 18 months previously had had good clinical results. After 15 months, however, arrhythmic attacks returned at increasing frequency. Withdrawal of amiodarone reversed the negative symptoms. The data shown in the table refer to the last three months of therapy and to the month after withdrawal of the drug. The main results are the constant decrease in total T3 and free T 3’ an increase in total T4 and in free T4, an increase in reverse T3, and no variation in T.B.G. and T.S.H. After the patient had been off the drug for a month all values had returned to normal. The increase in free T4 may have been responsible for the recurring arrhythmic attacks and for slight clinical symptoms of hyperthyroidism. In view of the conflicting results of previous data, which point to a "low T syndrome"3 we would stress that only with direct and accurate measurement of free fractions were we able to account for the changes induced by amiodarone. Institute
of Radiology, University of Ferrara, 44100 Ferrara, Italy Division of
Cardiology,
Arcispedale "S.
Anna", Ferrara
Dow-Lepetit, Milan
ADRIANO PIFFANELLI DARIO PELIZZOLA LUCIANO RICCI
LUCIANO CODECÁ ANTONIO MASONI PIER BRUNO ROMELLI
1. 2.
Pennisi, F., Romelli, P. B., Vanchieri, L. J. endocr. Invest. 1979, 2, 25. Burger, A., and others J. clin. Invest. 1978, 58, 255. 3. Jonckheer, M. H., and others. Clin. Endocr. 1978, 9, 27.
(SEPT., OCT., NOV.) AND AFTER ITS WITHDRAWAL (DEC.)
THYROID FUNCTION UNDER AMIODARONE THERAPY
