453
Integral to the difficulties of postgraduate education is the present organisation of the hospital service. Most inpatient care throughout the NHS is being delivered by unsupervised junior doctors trying to complete their medical training and teaching the next generation at the same time. "See one, do one, teach one" is an inappropriate way modem health service. The long-term solution lies in fully trained doctors providing more front-line care, and in a system of organised postgraduate education. The examinations are a symptom of a sick system, not its cause. SIMON J. ELLIS Radcliffe Infirmary, ANDREA H. NEMETH Oxford OX2 6HE, UK to run a
Ways of giving good
news
SIR,-Dr Brewin (May 18, p 1207) describes three ways to give bad news to patients with a newly discovered adverse prognosis. His insights into this aspect of medicine show a wisdom that is difficult to learn other than by long experience. Another important role of the doctor is the imparting of good news-ie, when an investigative procedure is normal. Variations in the presentation of good news parallel those Brewin discusses. The blunt and unfeeling strategy for delivering bad news that Brewin describes may be even more commonplace for good news. Merely telling the patient about negative results of a diagnostic test with little other discussion may allay the patient’s immediate fears but leaves questions unanswered. If symptoms or an earlier abnormal test remain unexplained, the patient may feel that the doctor does not have the expertise to deal with the particular problem. Alternatively, he may feel that the doctor does not believe that the symptoms are real. Too much reassurance while giving good news is the counterpart of the excessive consolation that is obvious in Brewin’s second strategy-the kind and sad way. Dogmatic reassurance solely on the basis of a negative test runs the risk of later criticism, either when a preclinical lesion becomes clinically manifest or when treatment by another doctor purportedly effects a cure. Brewin’s third strategy is a model for any type of patient encounter. The ingredients of flexibility based on patient feedback, positive thinking, reassurance, and planning for the immediate future that Brewin believes provide the best strategy for giving bad news are equally important with good news. The use of feedback is fundamental to the inclusion of the patient in the decision-making process. Grief is the usual response to bad news, but reactions to good news may be more varied, ranging from disappointment to relief. This broad spectrum of patient reaction makes feedback essential in deciding whether a follow-up visit, other diagnostic testing, or empirical therapy should be the next step. Planning for the immediate future is important whether news is good or bad. For a patient with persistent symptoms who is disappointed at not being able to document their suffering by a diagnostic test, the explanation of how time, alternative tests, a repeat test, and empirical therapy fit into the plan should be presented. Asking the patient whether they are happy with the proposed plan ensures that his symptoms are taken seriously, that he feels included in the management of the problem, and serves as a cue to the patient to close the encounter. The conveyance of news of diagnostic testing, whether bad or good, is an aspect of the doctor/patient relationship that receives short shrift in medical education. Junior doctors in training should often have the opportunity to observe other clinicians presenting information to patients. Unfortunately such opportunities are not as common as they might seem, because of fear of the time taken by patients and their family, the relative unimportance of the task, and the perceived need for one-to-one intimacy. This task of giving good news is viewed as time consuming and fairly unimportant-work too trivial for senior clinicians. The delegation of this responsibility to others reinforces the view that communication of good news is unimportant. With attention to reassurance and planning at this point in the doctor/patient encounter, the attending doctor would show the student the potential for saving time and avoiding future misunderstanding. Such teaching for the delivery of the bad news is also prevented by the desire for personal intimacy, which is probably correct. It is
envision how the presence of students who are not in the conversation and who may be even visibly uncomfortable is justifiable when patient confidentiality is at risk. Teaching of strategies in a didactic fashion is worthwhile but is susceptible to the same criticism of teaching of any humanistic aspect of medicine-ie, it is difficult, if not impossible. Emphasis on the doctor/patient relationship has only just begun to take its place in the medical curriculum, and although medical students now gain some exposure to such issues, more could be done, including teaching how to deliver news, good or bad, to the patient.
difficult
to
participating
Department of Internal Medicine, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina 27157, USA
JAMES L. WOFFORD
Kidney trading in Hong Kong SIR,-Dr Kandela has drawn attention (June 22, p 1534) to the illegal trade of kidneys in India. Similar events take place in Hong Kong. Although about 1000 patients are waiting for renal transplantation in Hong Kong only 50 such operations are completed annually. Half of these kidneys come from living-related donors and half come from cadaveric donors, mostly as a result of traffic accidents. The poor development of the Hong Kong renal transplant programme might be because of the traditional Chinese belief of dying in integrity. During recent years, nephrologists in Hong Kong have referred patients to China for renal transplantation. Kidneys are usually obtained from prisoners who are executed for offences such as rape, burglary, or political "crimes" against the state. No consent for organ removal is given by either the prisoner or the family. Furthermore, the family rarely collects the body after execution for fear of harassment by government authorities. Operations have been completed in regional teaching hospitals in Guangzhou (a southern city 80 miles from Hong Kong). Patients are discharged a few weeks later if no major complication occurs, and follow-up is undertaken by the referring physician in Hong Kong. The fee for the entire procedure is about CIO 000. Preoperative testing of blood group, hepatitis B surface antigen, antibody to human immunodeficiency virus, and HLA-tissue type is rarely done, and the frequency of graft rejection is high. Both the Hong Kong Medical Association and the government has condemned this practice. The government has also refused to supply cyclosporin to those patients who had transplants in China. Even these measures do not prevent people from going to China to buy a kidney. Organ trading occurs throughout the world. Doctors must ask governments to impose tighter controls over these practices and must also encourage more people to opt into voluntary kidney donation programmes. Department of Obstetrics and Gynaecology, Mary Hospital, Hong Kong
Queen
SIU-KEUNG LAM
Cosmetic surgery SiR,—The note (July 6, p 48) to which Mr Skanderowicz (July 27, p 260) responds clearly states that the plastic surgery work load is within the National Health Service. With few of the 140 consultant plastic surgeons in the UK exceptions, do private practice, possibily up to 80% of that time being spent on cosmetic surgery. With the possible exception of surgery to the aging face, all aspects of cosmetic surgery are taught late in training (senior registrar level) within NHS practice whenever possible, and what cannot be covered there is taught in the private sector. Surgery of the cleft lip/nose and breast reductions, reconstructions, and augmentations are all available to NHS patients along with dermabrasion, suction, lipolysis, and blepharoplasty. No-one would be qualified in plastic surgery if they were not familiar with all cosmetic aspects of this type of surgery. The Specialist Advisory Committees in plastic surgery rigorously examine training posts and have a representative of the British Association of Aesthetic Plastic Surgeons (BAAPS) as one of their members. His job is to examine the cosmetic experience of
referred
to
most
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
Integral to the difficulties of postgraduate education is the present organisation of the hospital service. Most inpatient care throughout the NHS is being delivered by unsupervised junior doctors trying to complete their medical training and teaching the next generation at the same time. "See one, do one, teach one" is an inappropriate way modem health service. The long-term solution lies in fully trained doctors providing more front-line care, and in a system of organised postgraduate education. The examinations are a symptom of a sick system, not its cause. SIMON J. ELLIS Radcliffe Infirmary, ANDREA H. NEMETH Oxford OX2 6HE, UK to run a
Ways of giving good
news
SIR,-Dr Brewin (May 18, p 1207) describes three ways to give bad news to patients with a newly discovered adverse prognosis. His insights into this aspect of medicine show a wisdom that is difficult to learn other than by long experience. Another important role of the doctor is the imparting of good news-ie, when an investigative procedure is normal. Variations in the presentation of good news parallel those Brewin discusses. The blunt and unfeeling strategy for delivering bad news that Brewin describes may be even more commonplace for good news. Merely telling the patient about negative results of a diagnostic test with little other discussion may allay the patient’s immediate fears but leaves questions unanswered. If symptoms or an earlier abnormal test remain unexplained, the patient may feel that the doctor does not have the expertise to deal with the particular problem. Alternatively, he may feel that the doctor does not believe that the symptoms are real. Too much reassurance while giving good news is the counterpart of the excessive consolation that is obvious in Brewin’s second strategy-the kind and sad way. Dogmatic reassurance solely on the basis of a negative test runs the risk of later criticism, either when a preclinical lesion becomes clinically manifest or when treatment by another doctor purportedly effects a cure. Brewin’s third strategy is a model for any type of patient encounter. The ingredients of flexibility based on patient feedback, positive thinking, reassurance, and planning for the immediate future that Brewin believes provide the best strategy for giving bad news are equally important with good news. The use of feedback is fundamental to the inclusion of the patient in the decision-making process. Grief is the usual response to bad news, but reactions to good news may be more varied, ranging from disappointment to relief. This broad spectrum of patient reaction makes feedback essential in deciding whether a follow-up visit, other diagnostic testing, or empirical therapy should be the next step. Planning for the immediate future is important whether news is good or bad. For a patient with persistent symptoms who is disappointed at not being able to document their suffering by a diagnostic test, the explanation of how time, alternative tests, a repeat test, and empirical therapy fit into the plan should be presented. Asking the patient whether they are happy with the proposed plan ensures that his symptoms are taken seriously, that he feels included in the management of the problem, and serves as a cue to the patient to close the encounter. The conveyance of news of diagnostic testing, whether bad or good, is an aspect of the doctor/patient relationship that receives short shrift in medical education. Junior doctors in training should often have the opportunity to observe other clinicians presenting information to patients. Unfortunately such opportunities are not as common as they might seem, because of fear of the time taken by patients and their family, the relative unimportance of the task, and the perceived need for one-to-one intimacy. This task of giving good news is viewed as time consuming and fairly unimportant-work too trivial for senior clinicians. The delegation of this responsibility to others reinforces the view that communication of good news is unimportant. With attention to reassurance and planning at this point in the doctor/patient encounter, the attending doctor would show the student the potential for saving time and avoiding future misunderstanding. Such teaching for the delivery of the bad news is also prevented by the desire for personal intimacy, which is probably correct. It is
envision how the presence of students who are not in the conversation and who may be even visibly uncomfortable is justifiable when patient confidentiality is at risk. Teaching of strategies in a didactic fashion is worthwhile but is susceptible to the same criticism of teaching of any humanistic aspect of medicine-ie, it is difficult, if not impossible. Emphasis on the doctor/patient relationship has only just begun to take its place in the medical curriculum, and although medical students now gain some exposure to such issues, more could be done, including teaching how to deliver news, good or bad, to the patient.
difficult
to
participating
Department of Internal Medicine, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina 27157, USA
JAMES L. WOFFORD
Kidney trading in Hong Kong SIR,-Dr Kandela has drawn attention (June 22, p 1534) to the illegal trade of kidneys in India. Similar events take place in Hong Kong. Although about 1000 patients are waiting for renal transplantation in Hong Kong only 50 such operations are completed annually. Half of these kidneys come from living-related donors and half come from cadaveric donors, mostly as a result of traffic accidents. The poor development of the Hong Kong renal transplant programme might be because of the traditional Chinese belief of dying in integrity. During recent years, nephrologists in Hong Kong have referred patients to China for renal transplantation. Kidneys are usually obtained from prisoners who are executed for offences such as rape, burglary, or political "crimes" against the state. No consent for organ removal is given by either the prisoner or the family. Furthermore, the family rarely collects the body after execution for fear of harassment by government authorities. Operations have been completed in regional teaching hospitals in Guangzhou (a southern city 80 miles from Hong Kong). Patients are discharged a few weeks later if no major complication occurs, and follow-up is undertaken by the referring physician in Hong Kong. The fee for the entire procedure is about CIO 000. Preoperative testing of blood group, hepatitis B surface antigen, antibody to human immunodeficiency virus, and HLA-tissue type is rarely done, and the frequency of graft rejection is high. Both the Hong Kong Medical Association and the government has condemned this practice. The government has also refused to supply cyclosporin to those patients who had transplants in China. Even these measures do not prevent people from going to China to buy a kidney. Organ trading occurs throughout the world. Doctors must ask governments to impose tighter controls over these practices and must also encourage more people to opt into voluntary kidney donation programmes. Department of Obstetrics and Gynaecology, Mary Hospital, Hong Kong
Queen
SIU-KEUNG LAM
Cosmetic surgery SiR,—The note (July 6, p 48) to which Mr Skanderowicz (July 27, p 260) responds clearly states that the plastic surgery work load is within the National Health Service. With few of the 140 consultant plastic surgeons in the UK exceptions, do private practice, possibily up to 80% of that time being spent on cosmetic surgery. With the possible exception of surgery to the aging face, all aspects of cosmetic surgery are taught late in training (senior registrar level) within NHS practice whenever possible, and what cannot be covered there is taught in the private sector. Surgery of the cleft lip/nose and breast reductions, reconstructions, and augmentations are all available to NHS patients along with dermabrasion, suction, lipolysis, and blepharoplasty. No-one would be qualified in plastic surgery if they were not familiar with all cosmetic aspects of this type of surgery. The Specialist Advisory Committees in plastic surgery rigorously examine training posts and have a representative of the British Association of Aesthetic Plastic Surgeons (BAAPS) as one of their members. His job is to examine the cosmetic experience of
referred
to
most
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
