Problems of inner city general practice in north-east London

This paper looks at differences in primary health care between the inner city and suburban areas of the North-East London Faculty of the Royal College of General Practitioners. Most of the differences observed were in the expected direction. However, the inner city area did not appear worse off in terms of the proportion of doctors specifically trained for general practice, the availability of doctors outside normal surgery hours, the links between general practitioners and hospitals and the attitudes of doctors to change. The data were derived from a postal survey of general practitioner principals whose main surgery was in the faculty area.     

The incidence and management of female breast disease in a general practice

A retrospective study is reported of 180 women with breast symptoms consulting at a group practice during a 27-month period. The management policies of the general practitioners are discussed in the light of the observed short-term outcomes and of proposals to introduce screening clinics for breast cancer.     

IgG subclass distribution of thyroglobulin antibodies in patients with thyroid disease

The IgG subclass distribution of thyroglobulin antibodies (TgAb) has been studied in Hashimoto and Graves’ patients by several investigators with conflicting results, in part explainable by methodological problems. We have recently developed a quantitative ELISA to measure in absolute terms the serum concentration of TgAb subclasses. The aim of the present study was to apply this method in a large series of patients with autoimmune as well as, for the first time, non-autoimmune thyroid diseases. We examined 28 patients with Hashimoto's thyroiditis, 30 with Graves’ disease, 21 with thyroid carcinoma and 18 with non-toxic goitre, all selected for the presence of TgAbs. The results indicated that TgAbs in thyroid diseases were not restricted to any particular isotype, but comprised all four IgG subclasses. IgG1 was represented similarly in the four groups. The same was true for IgG3, even though its contribution to the total antibody content was very small. IgG4 was the dominant subclass in patients with Graves’ disease, thyroid carcinoma and non-toxic goitre, probably reflecting a prolonged antigenic challenge. In Hashimoto's thyroiditis IgG2 was dominant, possibly because T helper lymphocytes infiltrating the thyroid are typically Th1 type.     

Continuing education in general practice in England and Wales

In 1970, a random sample of 9·5 per cent of general-practitioner principals in England and Wales were asked about continuing education; 53 per cent of them replied. Respondents preferred long intensive courses, thought that dissemination of information about national courses was defective, and the 32 per cent who required a locum before they could attend a course had difficulty in obtaining one. Local educational activity is enhanced by the presence of a postgraduate medical centre.     

Unusual presentations of thyroid disease in general practice

We report nine cases of unusual presentations of thyroid disease seen in our practice during a period of about two years. We discuss the implications and management of these cases in general practice.     

Prevalence of thyroid peroxidase, thyroglobulin and thyrotropin receptor antibodies in a long-term follow-up of juvenile Graves disease

OBJECTIVE: To relate the presence of thyroid peroxidase antibodies (TPO ab), thyroglobulin antibodies (Tg ab) and thyrotropin receptor antibodies (TSH-R ab) to the clinical course in a long-term follow-up of patients with juvenile Graves' disease (JGD). DESIGN: Patients with JGD were drawn from a Danish retrospective study and reexamined. RESULTS: A number of 105 patients were reexamined 4-21 years (median 10 years) after diagnosis. Three groups were formed: Gr.1: euthyroid patients with anti-thyroid drug (ATD) cessation more than 12 months before reexamination (n=41). Gr.2: patients still on ATD (n=24). Gr.3: subtotally thyroidectomized patients (n=40). Positive TPO ab titers were found in 75% of the patients. In 13% of the patients the titers were very high: >10,000 U/ml. Positive Tg ab were found in 51%. The prevalence of TPO ab and Tg ab was the lowest in group 3. Stimulating TSH-R ab titers were found in 13%. No patients had blocking TSH-R ab. The prevalence of TSH-R ab was 3% in the euthyroid patients, without surgery performed. 15% in the surgical patients, and 25% in the patients still on ATD. CONCLUSIONS: Many JGD patients were euthyroid at the long-term follow-up in spite of high TPO ab and Tg ab titers. Stimulating TSH-R ab were rare (13%). According to this presence of TPO ab, Tg ab or TSH-R ab does not predict the final outcome of JGD. Further studies are needed.     

Development of a thyroid function strategy for general practice.

A study was carried out to investigate a thyroid stimulating hormone (TSH) frontline strategy that could potentially result in a more straightforward interpretation of thyroid function tests, a reduction in the number of inappropriate referrals to medical outpatients, an improvement in the 'turnaround time' of results, and a reduction in the number of unnecessary tests carried out, thereby reducing costs.     

Increased heterogeneity of serum thyroglobulin in thyroid cancer patients as determined by monoclonal antibodies

Summary We investigated the immunological heterogeneity of plasma Tg in thyroid cancer patients using monoclonal antibodies in an immunoradiometric assay and a conventional RIA system with a polyclonal rabbit antibody. The results were compared with measurements of plasma Tg in patients with nonmalignant disease. We can demonstrate an increased immunological heterogeneity in tumor patients compared with patients with non-malignant thyroid diseases. In one case the Tg value measured by a monoclonal test system exceeded the value obtained by a polyclonal RIA system in the same sample by a factor of 25. It has to be further investigated whether this increase in heterogeneity is of diagnostic value in the follow-up of thyroid cancer patients.Abbreviations IRMA 11, IRMA 13 Immunoradiometric assay using mabTg 11 or mabTg 13 - mabTg monoclonal antithyroglobulin antibodies - Tg Thyroglobulin     

Attitudes towards practice nurses--survey of a sample of general practitioners in England and Wales.

Practice nursing has expanded rapidly since the 1990 contract for general practitioners. In 1990, a national survey was undertaken of the attitudes of a random sample of general practitioners towards practice nurses. Responses to the postal questionnaire were received from 41.9% of the 4800 general practitioners sampled. Of the responding general practitioners, 90.0% were satisfied with the role of the practice nurse within their practice. To fulfil the requirements of the 1990 contract for general practitioners 50.7% had created a new nursing post, and 83.1% had expanded the role of nurses already employed; 89.7% wished to see further expansion of the practice nurse's role. However, lack of space was the factor most frequently reported as limiting the expansion of the practice nurse's role, mentioned by 76.0% of general practitioners. Only 43.7% of general practitioners recognized lack of opportunities for practice nurse training as a hindrance to role expansion. The key to managing the expansion of the role of the practice nurse lies in the provision of resources and in training. A pressing need exists for a national training scheme based in general practice.     

Anti-human thyroid peroxidase and anti-human thyroglobulin antibodies present no cross-reactivity on recombinant peptides.

Thyroglobulin (Tg) and thyroid peroxidase (TPO) are two antigens largely recognized by the sera from patients with autoimmune thyroid disease (AITD). Recently, the complete mapping of both antigens was established with rabbit polyclonal antibodies by the use of recombinant proteins expressed in prokaryotic vector. Several investigators have argued for the existence of a cross-reactivity of some hetero- and autologous antibodies versus these two proteins. In the present study, using rabbit polyclonal antibody, mouse polyclonal antibody and autoimmune antibody (aAb), we observed no common epitope on human Tg (hTg) and human TPO (hTPO).     

甲状腺球蛋白抗体和甲状腺过氧化物酶抗体定量检测在甲状腺肿大患者病因诊断上的应用

目的探讨甲状腺球蛋白抗体(TGAb)和甲状腺过氧化物酶抗体(TPOAb)定量检测在甲状腺肿大患者病因诊断上的应用。方法对291例甲状腺肿大患者血清和86例正常人血清用直接化学发光定量检测TGAb和TPOAb,并对甲状腺肿大患者检测甲功5项。结果甲状腺肿大患者TGAb和TPOAb浓度分别为(254±417)U/ml和(1001±1108)U/ml,有124例确诊为自身免疫性甲状腺炎(AITT),90例诊断为单纯性甲状腺肿大;AITT患者TGAb和TPOAb浓度和抗体检出率明显高于非AITT患者,P<0.01。结论定量检测血清TGAb和TPOAb对甲状腺肿大患者在病因诊断上有重要意义。     

The incidence and clinical symptomatology of Clostridium difficile infections in a community setting in a cohort of Danish patients attending general practice

Clostridium difficile infection (CDI) is gradually being recognised as a cause of morbidity in the community. We investigated the incidence and clinical characteristics of CDI in a community setting and characterised the C. difficile strains by toxin gene profiling and polymerase chain reaction (PCR) ribotyping. Patients included in the study had attended general practice, primarily because of diarrhoea; CDI patients (259 patients; 121 <2 years of age) had positive cultures for toxigenic C. difficile and non-CDI patients (455 patients) were culture-negative. Outcome variables included the frequency and duration of diarrhoea, vomiting, stomach ache, fever >38 °C, weight loss and sick leave. Data were analysed by logistic regression. CDI patients <2 and ≥2 years of age with C. difficile as the only enteropathogen in the faecal sample reported slimy stools (65 % vs. 62 %), stomach ache (60 % vs. 75 %), weight loss (50 % vs. 76 %) and duration of diarrhoea >15 days (59 % vs. 73 %) as the predominant symptoms. CDI patients ≥2 years old reported duration of diarrhoea >15 days more often compared to non-CDI patients (73 % vs. 27 %, p?<?0.0001). The annual incidence of CDI was 518 and 23/100,000 for patients <2 and ≥2 years of age, respectively, and 46/100,000 in the subgroup of patients ≥60 years of age. CDI was characterised by stomach ache and persistent diarrhoea, often leading to weight loss. This emphasises the importance of diagnosing CDI not only in hospitalised patients, but also in individuals ≥2 years of age attending general practice because of gastrointestinal symptoms, especially in the elderly, where the incidence of CDI is high.     

The cryptic self in thyroid autoimmunity: the paradigm of thyroglobulin

Recent studies have increased the number of known thyroiditogenic sites in thyroglobulin (Tg) to thirteen. These sites contain T-cell epitopes and are scattered throughout Tg, with nine of them localized toward the carboxyl terminal third of the molecule. So far, no pathogenic determinant has been found to be dominant, i.e. to be readily and consistently generated in extrathyroidal antigen-presenting cells (APC) following processing of intact Tg in vivo and in vitro. However, certain conditions, such as internalization of Tg-antibody complexes or enhanced iodination of Tg, have been described to promote generation of cryptic pathogenic peptides in APC, in vitro. These findings support the view that post-translational events can "unmask the cryptic self' and suggest mechanisms that may contribute to the pathogenesis of thyroiditis.