Volume 70 October 1977

741

Letters to the Editor Evaluation of Preclinical Hypothyroidism From Dr J J Staub Consultant in Endocrinology, Kantonsspital, CH-4031 Basel, Switzerland Dear Sir, In his editorial 'Premyxcedema - a Cause of Preventable Coronary Heart Disease' (May Proceedings, p 297) Dr Fowler raises several interesting questions with very important practical consequences. The biochemical finding of elevated TSH before and/or after TRH with normal levels for thyroxine (T4) and triiodothyronine (T3) is a new clinical entity and our knowledge of its natural history is still incomplete. Only long-term followup studies will give answers to the various questions raised in this editorial. The majority of patients with this condition remain euthyroid and only a minority develop overt hypothyroidism (Evered et al. 1973, Toft et al. 1975, Khangure et al. 1977). Therefore, the need for treatment with thyroxine is controversial. For practical purposes the guidelines given by Dr Fowler seem convincing and are based on his studies of premyxedema (Fowler & Swale 1967, Greenwood & Fowler 1976). In order to evaluate preclinical hypothyroidism and to be certain of the need for lifelong treatment, we use creatinephosphokinase (CPK) and the stimulation of triodothyronine by oral TRH, as well as cholesterol and ankle reflex time. Like Dr Fowler we have found patients with preclinical hypothyroidism and normal cholesterol, but increased reflex time. More often, however, patients have a normal reflex time, but elevated CPK. Therefore, we believe that the measurement of this enzyme should be included in the evaluation of preclinical hypothyroidism. Furthermore, we think that the oral TRH-TSH-T3 stimulation test could be used as a prognostic tool. Oral TRH (in a dose of 40 mg) is a potent stimulator for the pituitary thyrotrophs, producing a prolonged release ofTSH (like a depot preparation) which leads to an important increase of T3 in most euthyroid patients, but not in hyper- and hypothyroid patients (Staub et al. 1976, Staub et al. 1978). We found three different types of T3 response in preclinical hypothyroidism: (1) complete failure of T3 response; (2) normal T3 stimulation; (3) exaggerated T3 increase. The diminished T3 response (confirmed on two occasions) can be regarded as the consequence of a limited reserve of thyroid hormone production. A normal or exaggerated

response of T3 to oral TRH is evidence of a good thyroid reserve. A limited number of patients in each group have been followed up: several patients from the first group developed overt hypothyroidism within 6-30 months. The majority of patients from the second and third groups, however, remained euthyroid over the period of observation. The value of this TRH-TSH-T3 stimulation test as a further index of the need for treatment can only be evaluated by a prospective study which has been in progress here for 21 years. The stimulation of the thyroid cells by endogenous TSH seems to give a more sensitive index of thyroid reserve than the response to pharmacological exogenous TSH, as judged by the TRH-TSH-T3 stimulation test. However, further experience is needed to determine the value of this test. Yours sincerely J J STAUB

20 July 1977 REFERENCES Evered D C, Ormston B J, Smith P A, Hall R & Bird I (1973) British Medical Journal i, 657 Fowler P B S & Swale J (1967) Lancet i, 1077 Greenwood T W & Fowler P B S (1976) Proceedings of the Royal Society of Medicine 69, 225 Khangure M S, Dingle P R, Stephenson J, Bird T, Hall R & Evered D C (1977) Clinical Endocrinology 6, 41 Toft A D, Irvine W J, Seth J, Hunter W M & Cameron E H D (1975) Lancet ii, 576 Staub J J, Girard J, Gemsenjaeger E and Mueller-Brand J (1976) European Journal of Clinical Investigation 6, 317 Staub J J, Girard J, Mueller-Brand J, Noelpp B, Werner-Zodrow 1, Baur U, Heitz Ph & Gemsenjaeger E (1978) Journal of Clinical Endocrinology (in press)

Marital Counselling and the General Practitioner From Dr G N Marsh Norton Medical Centre, Stockton-on- Tees, Cleveland Dear Sir, I am writing to support Dr J S H Cohen (July Proceedings, p 495) on the value of a marriage guidance counsellor in the day-to-day work of general practice. For the past four years, this practice has worked closely with a series of three marriage counsellors (usually two at any one time), who have held consultations in the surgery for up to twenty hours per week. In all, several hundred patients/clients have been counselled on problems as diverse as infertility, desertion, infidelity, sexual dysfunction,

742

Proc. roy. Soc. Med. Volume 70 October 1977

physical violence, alcoholism and various pathological mental states, especially depression. most of these patients have presented initially with some form of anxiety state, depressive illness or general malaise to their general practitioner. At the beginning, referrals came from the one doctor in the practice who had been most eager to explore this liaison, but after a few months all the doctors in the practice were making, and continued to make, referrals. Furthermore, other members of the primary health care team - nurses, health visitors, midwives and social workers - have all referred patients. This was facilitated by the counsellors meeting the team regularly at the busy morning meetings, and also by one of them attending the monthly house committee meeting where practice policies are formulated. Hence, it appears that this is not a style of caring applicable only to one or two enthusiastic doctors, but has a general value to many doctors and also the fellow professional members of the primary health care teams. For those practices interested in developing more formal links with marriage counsellors in their own areas, the methods by which the system was established in Stockton-on-Tees and the advantages to patient, doctor and counsellor have been described (Marsh G N & BarrJ, 1975, Journal oJ the Royal College of General Practitioners 23, 73-75). Yours sincerely G N MARSH

1O July 1977 Breast Cancer From Mr W P Greening Consultant Surgeon, Breast Unit, Royal Marsden Hospital, London SW3 6JJ Dear Sir, I read with great interest Ian Burn's excellent editorial on breast cancer (August Proceedings, p 515) and I must congratulate him on covering the subject in such a short space. The important prognostic significance of involvement of the axillary lymph nodes is stressed and it is emphasized that with minimal deposits in the low nodes an adequate axillary clearance is mandatory if long survival is to be expected. The TNM staging is discussed, but perhaps more emphasis might have been placed on the inaccurate estimation of the size of the primary tumour on clinical exa.mination and the value of mammography in determining size. The detection of occult distant metastases is covered fully, but perhaps the natural history of the disease has not been taken into account. For example, it is accepted that a breast tumour may increase in size to- only 3 cm over a period of ten years and presumably osseous microfoci will re-

main overt for a considerable time after treatment is instituted. Many cases with a positive bone scan may survive with no clinical evidence of dissemination for periods up to ten years. The reverse applies; some breast tumours will grow rapidly. This can be seen in any screening clinic where the interval cancers have an extremely poor prognosis and although they are early when first seen the treatment, no matter how well planned, will not influence the course of the disease. I agree that there is as yet no hard evidence that adjuvant cytotoxic therapy increases the survival time, but the results of this modality of treatment will be known within the next two years. Immunotherapy should not be dismissed too lightly. The host defence reaction seen in- the medullary carcinomas with lymphocytic infiltration is surely an example of an immune response. Yours faithfully W P GREENING

5 August 1977 From Mr R S Handley Harley Street, London WIN IDG Dear Sir, Mr Ian Burn's admirable editorial (August, p 515) on the problems which face us in the treatment of breast cancer has emphasized my own feeling that the more I study this dreadful disease, the less I understand it. But one cannot have spent a professional lifetime in treating it without having formed some personal opinions. I do not believe that there is such a thing as early breast cancer. Evidence steadily accumulates that malignant cells from breast carcinomata gain early access to the blood stream, often before any clinical sign is apparent. Experience, however, shows that we do sometimes cure the disease, and it is my conviction that the immune mechanism of the body, by dealing with small numbers of circulating cells, is responsible for our success. Our treatment reduces the load which the immune response is called on to handle. The methods we use to diminish this load involve operative trauma,

radiotherapy and sometimes chemotherapeutic drugs, all of which are known to reduce the immune responses, but it must be that we usually do more good than harm by our interference. The outcome of our efforts probably depends on the balance between the malignancy of the tumour and the efficiency of the immune mechanisms, and is comparable with the outcome of an infection where the virulence of an organism and the competence of the host's resistance would, in the absence of antibiotics, decide the result. The editorial states that one factor determining curability is the involvement or otherwise of the regional lymph nodes. This has been proved; but it seems to me that it is not only the lapse of time but

Marital counselling and the general practitioner.

Volume 70 October 1977 741 Letters to the Editor Evaluation of Preclinical Hypothyroidism From Dr J J Staub Consultant in Endocrinology, Kantonsspit...
331KB Sizes 0 Downloads 0 Views