Автономия Медицинских профессионалов.

RCP отнял у врачей право высказывать свое профессиональное суждение.

 

Согласно обзору «Medicines and Healthcare Regulatory Agency (MHRA)» в разделе Нелицензированные Лекарства, есть пункт: “врачи в соответствующих обстоятельствах могут представить свое профессиональное суждение для комиссии поставок нелицензионных лекарств с целью удовлетворения особых потребностей конкретного пациента”.²³⁷

 

Отобрав у врача автономиию, программное заявление RCP является принудительным. Закон не любит нерешенных вопросов, и будет следовать за общепринятой интерпретацией. В данном случае-бойкотировать все альтернативы левотироксина натрия. Врач, который осмеливается бросить вызов медицинскому руководству в интересах пациента, может оказаться в затруднительном положении и понести значительные и дорогостоящие дисциплинарные наказания от GMC, даже если врач лечит своего пациента с этической и научной точки зрения правильно.
.

Поэтому врачи опасаются влияния RCP на GMC. Они боятся потерять свою работу и средства к существованию, если осмелятся проводить диагностику или лечение больных вразрез политике, которая выходит за рамки первичного гипотиреоза. Страх перед судебным преследованием заставляет их соглашаться. Это согласие препятствует правильной диагностике и лечению больных. Программное заявление RCP уже выходит за рамки первичного гипотиреоза и крайне вредно для пациентов и врачей.

 

Цитата от пациента из петиции «Международный Гипотиреоз».238 “Из-за невежества, высокомерия, непонимания врачей в поисках диагностики и лечения я был доведен до ярости, как лампа накаливания. Даже в качестве квалифицированного специалиста в области здравоохранения, работающего на крупных DGH, я не в силах помешать риску потерять здоровье в долгосрочной перспективе, связанному с отсутствием лечения; я безмолвен, стерилизован, мне покровительствуют, и я ползаю изо дня в день через то, что раньше было моей витальной и яркой жизнью. Я бы отдал все, что имею, чтобы вновь стать открытым мыслящим и творческим диагностом, и еще немного сострадания, но это, похоже,полностью за пределами возможностей современного врача. Боже, помоги нам всем.”

 

References

· Joint Committee on Higher Medical Training, “Higher Medical Training Curriculum for Endocrinology and Diabetes Mellitus,” 2003, 5 Saint Andrews Place, Regent’s Park, London NW1 4LB

· Good Medical Practice: Teaching and training, appraising and assessing. http://www.gmc-uk.org/guidance/good_medical_practice/teaching_training.asp

· Map of Medicine: Royal College of Physicians Joint specialty societies. http://eng.mapofmedicine.com/evidence/map/thyroid_disorders1.html

· Goldberg M, The Case For Euthyroid Hypometabolism, Am J Med Sc October, 1960 pgs 479-493

· Goldberg M, Diagnosis of Euthyroid Hypometabolism, Am J Obst & Gynec, 81(5): 1053-1058, 1961

· Baisier, WV, Hertoghe, J., Beekhaut, W., Thyroid Insufficiency? Is Thyroxine the Only Valuable Drug?, Journal of Nutritional and Environmental Medicine, Vol. 11, No. 3, September 2001, pages 159-166

· Braverman LE, Ingbar SH, Keinwem S, Conversion of Thyroxine (T4) to Triiodothyronine (T3) in Athyreotic Human Subjects, The J Clin Invest, 1970

· Danzi S, Ojamaa K, and Klein I, Triiodothyronine-Mediated Myosin Heavy Chain Gene Transcription in the Heart, Am J Phys Heart Circ Physiol, Feb 27, 2003

· Eisenstein Z, Hagg S, Braverman LE, et al., Effect of Starvation on the Production and Peripheral Metabolism of 3,3',5' Triiodothyronine in Euthyroid Obese Subjects, J Clin Endocrinol Metab, 1978, 47(4): 889-893

· Nomura S., et al. Reduced Peripheral Conversion of Thyroxine to Triiodothyronine in Patients with Hepatic Cirrhosis, J of Clin Invest, Sept 1975, 56(3): 643-652

· Refetoff S, Dewind LT, DeGroot LJ, Familial Syndrome Combining Deaf-mutism, Stippled Epiphyses, Goiter and Abnormally High PBI: Possible Target Organ Refactoriness to Thyroid Hormone, J Clin Endocrinol Metab, 27:279, 1967

· Refetoff S, Weiss RE, Usala SJ, The Syndromes of Resistance to Thyroid Hormone, Endocr Rev, 1993, 14(3):348-399

· Weiss RE, Refetoff S, Treatment of Resistance to Thyroid Hormone – Primum Non Nocere, J Clin Endocr Metabol, 84(2):401-404.

· Thyroid Patient Advocacy sponsored a registry of counterexamples, numbering just under 2000 (Mar. 2012). http://www.tpa-uk.org.uk/register_of_counterexamples.php

· http://www.rcplondon.ac.uk/sites/default/files/the-diagnosis-and-management-of-primary-hypothyroidism-revised-statement-14-june-2011_2.pdf

· Saravanan P, Chau F, Roberts N, Vedhara K, Greenwood R, Dayan CM, 2002, Psychological Well-Being in Patients on "Adequate" Doses of L-Thyroxine Results of a Large, Controlled Community-Based Questionnaire Study, Clinical Endocrinology, 2002, 57: 577-585

· Robert H. Seller, MD and Andrew B. Symons, MD, MS ‘Differential Diagnosis of Common Complaints’, 6th Edition. ISBN: 9781455707720

· Differential Diagnosis (DDX) Definition: “The distinguishing of a disease or condition from others presenting with similar signs and symptoms,” Merriam-Webster

· Differential Diagnosis (DDX) ”is a systematic method used to identify unknowns. This method, essentially a process of elimination, is used by taxonomists to identify living organisms, and by physicians and other qualified professionals to diagnose the specific disease in a patient. Not all medical diagnoses are differential ones: some diagnoses merely name a set of signs and symptoms that may have more than one possible cause, and some diagnoses are based on intuition or estimations of likelihood.” Wikipedia: http://en.wikipedia.org/wiki/Differential_diagnosis

· Differential Diagnosis is a medical adaption of the process of elimination. These processes are based upon the logic of disjunctive syllogism, which is known from antiquity as modus tollendo poner

· Geisler NL, Brooks RM, Come, Let Us Reason, Baker Book House, original printing 1990

· A. P. Weetman. Whose Thyroid Hormone Replacement is it Anyway? Clin Endocrinol. 2006;64(3):231-233.

· Sharpe M, Carson A, “Unexplained Somatic Symptoms, Functional Syndromes, and Somatization: Do We Need a Paradigm Shift?, Ann Intern Med, 2001, 134:926-930

· Refetoff S, Weiss RE, Usala SJ, The Syndromes of Resistance to Thyroid Hormone, Endocr Rev, 1993, 14(3):348-399

· Braverman LE, Ingbar SH, Keinwem S, Conversion of Thyroxine (T4) to Triiodothyronine (T3) in Athyreotic Human Subjects, The J Clin Invest, 1970, 49

· Wrutniak-Cabello C, Casas F, Cabello G, Thyroid Hormone Action in Mitochondria, J Molec Endocrin, (26) 67-77, 2001

· Vanderpump MPJ, Ahlquist JAO, Franklyn JA, et al., Consensus Statement for Good Practice and Audit Measures in the Management of Hypothyroidism and Hyperthyroidism, BMJ, August 1996

· UK Guidelines for the Use of Thyroid Function Tests, The Association for Clinical Biochemistry, British Thyroid Association, British Thyroid Fndtn, 2006, www.british-thyroid-association.org/guidelines.htm

· The Diagnosis and Management of Primary Hypothyroidism, Royal College of Physicians, 2008

· Goldberg M, The Case For Euthyroid Hypometabolism, Am J Med Sc October, 1960 pgs 479-493

· Baisier, WV, Hertoghe, J., Beekhaut, W., Thyroid Insufficiency? Is Thyroxine the Only Valuable Drug?, Journal of Nutritional and Environmental Medicine, Vol 11, No. 3, September 2001, pages 159-166

· Turner S. Patient Counterexample Registry, Thyroid Patient Advocacy

· Dillman E, Gale C, Green W, et al. Hypothermia in iron deficiency due to altered triiodithyroidine metabolism. Regulatory, Integrative and Comparative Physiology 1980;239(5):377-R381.

· Smith SM, Johnson PE, Lukaski HC. In vitro hepatic thyroid hormone deiodination in iron-deficient rats: effect of dietary fat. Life Sci 1993;53(8):603-9.

· Zimmermann MB, Köhrle J. The Impact of Iron and Selenium Deficiencies on Iodine and Thyroid Metabolism: Biochemistry and Relevance to Public Health. Thyroid 2002;12(10): 867-78.

· Beard J, tobin B, Green W. Evidence for Thyroid Hormone Deficiency in Iron-Deficient Anemic Rats. J. Nutr. 1989;119:772-778.

· Jabbar A, Yawar A, Waseem S, Islam N, Ul Haque N, Zuberi L, Khan A, Akhter J. Vitamin B12 deficiency common in primary hypothyroidism. Department of Medicine, Aga Khan University, Karachi, Pakistan. 2008 May;58(5):258-61.

· Julia Bársony, P. Lakatos, J. Földes and T. Fehér. Effect of vitamin D3 loading and thyroid hormone replacement therapy on the decreased serum 25-hydroxyvitamin D level in patients with hypothyroidism: Acta Endocrinol November 1, 1986 113 329-334

· B. CATARGI, F. PARROT-ROULAUD, C. COCHET, D. DUCASSOU, P. ROGER, and A. TABARIN. Thyroid. December 1999, 9(12): 1163-1166. doi:10.1089/thy.1999.9.1163. Published in Volume: 9 Issue 12: January 30, 2009

· Bjørn G. Nedrebø, Ottar Nygård, Per M. UelandHYPERLINK "http://www.clinchem.org/content/47/9/1738.full", and Ernst A. Lien; Plasma Total Homocysteine in Hyper- and Hypothyroid Patients before and during 12 Months of Treatment. Clinical Chemistry September 2001 vol. 47 no. 9 1738-1741

· JOHN E. JONESt PAUL C. DESPER, STANLEY R. SHANE, AND EDMUND B. FLINK.Magnesium Metabolism in Hyperthyroidism and Hypothyroidism: Journal of Clinical Investigation. Vol. 45, No. 6, 1966

· Lawrence Wilson, MD.COPPER TOXICITY SYNDROME Revised, July 2011, The Center For Development. http://www.drlwilson.com/articles/copper_toxicity_syndrome.htm

· Vivek R Joshi, Ayaz K Mallick, Manjunatha Goud B K, Ravindra Maradi, Maheshwar G Reddy, Raghavendra Tey, Gaurav Shorey. Effect of serum copper concentration and ceruloplasmin on lipid parameters leading to increased propensity to cardiovascular risk. Department of Biochemistry, Melaka Manipal Medical College, Manipal University. ISSN: 0975-8585

· Iham Amir Al-Juboori, Rafi Al-Rawi, Hussein Kadhem A-Hakeim. Estimation of Serum Copper, Manganese, Selenium, and

· Zinc in Hypothyroidism Patients. IUFS Journal of Biology Short Communication 121 IUFS J Biol 2009, 68(2): 121-126

· Rajagopal KR, Abbrecht PH, Derderian SS, Pickett C, Hofeldt F, Tellis CJ, Zwillich CW. Obstructive sleep apnea syndrome and hypothyroidism (a report of three cases)].Ann Intern Med. 1984 Oct; 101(4):491-4.

· Rack SK, Makela EH. Hypothyroidism and depression: a therapeutic challenge Department of Behavioural Medicine and Psychiatry. Ann Pharmacother 2000 Oct; 34(10):1142-5

· Jonathan Stephen Murray, Rubaraj Jayarajasingh, Petros Perros. Deterioration of symptoms after start of thyroid hormone replacementBMJ.2001 August 11; 323(7308):332-333

· Annane D, Sébille V, Charpentier C, Bollaert PE, François B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troché G, Chaumet-Riffaud P, Bellissant E.Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002 Aug 21;288(7):862-71.

· C. Orian Truss, M.D. Restoration of Immunologic Competence to Candida Albicans [http://orthomolecular.org/library/jom/1980/pdf/1980-v09n04-p287.pdf]

· Diabetes Care January 2011 vol. 34 no. Supplement 1 S11-S61

· McDermott JH, Coss A, Walsh CH. Celiac disease presenting as resistant hypothyroidism. Thyroid. 2005 Apr;15(4):386-8.

· BRUCE H. COHEN, MD, DEBORAH R. GOLD, MD. What we know so far.Cleveland Clinic Journal of Medicine Volume 68.No 7; July 2001

· Rees-Jones RW, Larsen PR. Triiodothyronine and thyroxine content of desiccated thyroid tablets. Metabolism. 1977 Nov;26(11):1213-8

· Mangieri CN, Lund MH. Potency of United States Pharmacopeia desiccated thyroid tablets as determined by the antigoitrogenic assay in rats. J Clin Endocrinol Metab. 1970 Jan;30(1):102-4

· Gaby AR. Sub-laboratory hypothyroidism and the empirical use of Armour thyroid. Altern Med Rev. 2004 Jun;9(2):157-79

· Hertoghe T, Lo Cascio A., Hertoghe J. Considerable improvement of hypothyroid symptoms with two combined T3-T4 medication in patients still symptomatic with thyroxine treatment alone. Anti-Aging Medicine (Ed. German Society of Anti-Aging Medicine-Verlag 2003) 2004; 32-43

· Hertoghe T. Many conditions related to age reduce the conversion of thyroxine to triiodothyronine - a rationale for prescribing preferentially a combined T3 + T4 preparation in hypothyroid adults. Anti-Aging Medical Therapeutics 2000; IV: 138-53 T3-T4 (and T3) treatments work better than T4

· Saravanan P, Simmons DJ, Greenwood R, Peters TJ, Dayan CM. Partial substitution of thyroxine (T4) with tri-iodothyronine in patients on T4 replacement therapy: results of a large community-based randomized controlled trial. Clin Endocrinol Metab. 2005 Feb;90(2):805-12

· Kloppenburg M, Dijkmans BA, Rasker JJ. Effect of therapy for thyroid dysfunction on musculoskeletal symptoms. Clin Rheumatol. 1993 Sep;12(3):341-5

· Hertoghe T, Lo Cascio A., Hertoghe J. Considerable improvement of hypothyroid symptoms with two combined T3-T4 medication in patients still symptomatic with thyroxine treatment alone. Anti-Aging Medicine, Ed. German Society of Anti-Aging Medicine-Verlag 2003- 2004; 32-43

· Pareira VG, Haron ES, Lima-Neto N, Medeiros-Neto GA. Management of myxedema coma: report on three successfully treated cases with nasogastric or intravenous administration of triiodothyronine. J Endocrinol Invest. 1982;5:331-4

· Chernow B, Burman KD, Johnson DL, McGuire RA, O'Brian JT, Wartofsky L, Georges LP. T3 may be a better agent than T4 in the critically ill hypothyroid patient: evaluation of transport across the blood-brain barrier in a primate model. Crit Care Med. 1983 Feb;11(2):99-104

· Arlot S, Debussche X, Lalau JD, Mesmacque A, Tolani M, Quichaud J, Fournier A. Myxoedema coma: response of thyroid hormones with oral and intravenous high-dose L-thyroxine treatment. Intensive Care Med. 1991;17(1):16-8 T3-T4 treatment: adding T3 to T4 results in greater improvement of clinical symptoms and signs in hypothyroid patients

· Benevicius R, Kazanavicius G, Zalinkovicius R, Prange AJ. Effects of thyroxine as compared with thyroxine plus triiodothyronine in patients with hypothyroidism. N Engl J Med.1999; 340: 424-9.

When T3 and T4 are both supplemented to the food simultaneously with goitrogens, a much better prevention of goiter is obtained than when solely T4 is added, even if T4 is given at doses 7 times higher those of T3-T4 treatments

· Devlin WF, Watanabe H. Thyroxin-triiodothyronine concentrations in thryoid powders. J Pharm Sci. 1966 Apr;55(4):390-3