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The Evolving Patient

Joanne Shaw (22/05/2008 10:08:31)

Fat, mad, middle aged, menopausal women

I had a surprising encounter yesterday with two cheerful and competent women who run support groups for patients with thyroid disease. Here’s their view of the hot issues for thyroid patients:

not being taken seriously and being talked down to by GPs
having test results withheld by receptionists - being told they are allowed to know that they are normal, but not the detail
being charged £50 for special consultations if they want to know their full results.

I was truly amazed.

The ladies reassured me that these problems are far from universal. For example, some practices are happy routinely to fax full results to patients without charge, which is much appreciated. But people ringing patient support groups to ask for advice regularly report negative experiences of this kind.

This is an anecdote, not evidence, and hopefully it’s not a fair reflection of most people’s experience. I may be naïve but surely care like this is incompatible with an NHS that works in partnership with patients and encourages them to take responsibility for their own health.

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Comments [69]

Dan Brett

Posted: 22/05/2008 12:06:28

Joanne - tell the "goitre girls" to find a new hobby!
Here are some facts to save an unecessary fax
Under-active thyroid disease (which nearly all our thyroid patients are) doesn't need support - It's very simple - keep taking the tablets - if you do, you will have a normal blood test once a year - no GP consulatation required - end of story!
If you don't believe me got to: www.btf-thyroid.org
Don't make an issue of something that's not - we've got PCTs to do that job...
PS I like the £50 fining system for ridiculous consultation requests, though I'm not sure its currently strictly kosher under our terms of service

J Jones

Posted: 23/05/2008 01:27:18

But the question here Dan Brett (though perhaps it only arises for GPs with critical faculties intact) is what exactly constitutes a normal range for TSH?

Since 2003, the American Assoc. of Clin. Endocrinologists has stated that the normal range for TSH should be 0.3-3.04. Britain (supposedly a developed country) is retrogressive in having its patients wait until their TSH hits 10 before commencing treatment. (Cf. the BTF's recommendations). US researchers had the good sense to use a valid methodological approach and screen 'normal range study' participants for occult thyroid dysfunction. A shame the BTF and UK doctors can't learn from those with more advanced research skills.

The fact is, defining the normal TSH so broadly saves GPs lots of money but leaves lots of patients suffering.

J Jones

Posted: 23/05/2008 02:11:22

Dan Brett's post is a great example of the uneducated and ill-mannered treatment of thyroid patients (the majority of whom are female) by many UK medics. Can we expect to see Brett posting on blogs about male impotence telling the 'impotent idiot brigade' to find a new hobby?

In what way is asking for one's full results a 'ridiculous consultation request' that deserves a £50 fine? Perhaps Brett should be mindful of the GMC's guidance to 'give patients the information they want or need'.

Note to Brett's appraiser - it seems Brett has missed out on some basic training in the areas of respect for patients, information provision, diversity and equality. Perhaps you could organise for him to attend his Trust's next course in Equality and Diversity for Beginners.

Dan Brett

Posted: 23/05/2008 07:38:34

Excellent! The goitre girls have a new champion in Dr J 'Indiana' Jones! As a sequel to Ms Shaw's "101 ways to waste GPs time" we have "J Indiana Jones and the Last Crusade for the Missing Thyroxine". Between them, with their bullwhips, they are able to turn simple monitoring into a wimmin's occult, cult issue - fantastic! As long as the Trust Equality and Diversity Police don't get to me I will continue to give my patients what they need, using our local normal ranges for TSH, free T3 / T4 and thyroid autoantibodies, and if my patients want more than that they can discuss it with an endocrinologist - privately... in America if necessary...

John Squire

Posted: 23/05/2008 11:45:40

Are Goitre Girls a girl band?

Mary Shomon

Posted: 23/05/2008 16:47:22

It's no surprise to hear how contemptuous some NHS doctors are toward patients. It's worlwide common knowledge that NHS docs are inadequate in thyroid care. A clear example is the willful ignorance evident in Brett's commentary.

While many NHS doctors may have an appalling lack of knowledge of proper thyroid diagnosis and treatment, that can eventually be addressed through education. Sadly, however, there's little to be done about contemptuous, misoygnistic doctors who deride patients as "fat, mad, middle-aged, and menopausal" or "goitre girls." These are fundamental character and personality defects; no amount of continuing education will ever improve. No patient deserves to suffer this sort of incompetence.

Here's a fact: NHS doctors use outdated TSH reference ranges. Perhaps Brett and colleagues should spend less time offering uninformed opinion on blogs, and more time boning up on Endocrinology 101, so they can learn the basics.

Mary Shomon
Thyroid Patient Advocate

Talia Newman

Posted: 23/05/2008 16:58:39

So you actually run the free T3/T4 and autoantibodies test at your practise? Well,at least thats an improvement from the usual current practise of running the TSH only.
Your other comments are deplorable.What about that Hippocratic oath you undertook? For Gods sake,show some compassion for your fellow man(albeit)woman.
And try to back up scientifically what the hell you are talking about.In cases of Central Hypothyroidism and problems with the Pituitary gland the TSH 'normal' level is skewed and the patient can still be hypothyroid.If your patients have to resort to paying privately to see an Endocrinoligist it is a bad reflection on yourself and makes clear you dont know enough about Thyroid disease. Inadvertently,youve just admitted this.

Perhaps a change of career is in order.How about a comic?

Mary Shomon

Posted: 23/05/2008 17:17:23

@Jane -- Unfortunately, Brett would have to be witty or funny to pursue a career as a comic, and as is abundantly evident, he is neither.

Patching up fellows who have injured themselves bashing into each other playing rugby seems to be an appropriate challenge for his medical skills, however. ;-)

Sadequr Rahman

Posted: 25/05/2008 10:40:52

I read the above so-called debate with astonishment - have we now resorted to the type of name-calling, personal insults and paranoia I normally read on sci-fi blogs? There appear to be a few issues in question here, not all related, so lets look at the facts.

Sadequr Rahman

Posted: 25/05/2008 10:41:05

1) To JS re: receptionists and results. Receps were previously allowed to divulge results. Unfortunately nowadays most patients demand a full battery of unnecessary and expensive tests, and the average practice will receive hundreds of such results daily. Receps do not have the time to read out all these numbers, and they are not trained to tell patients what to do with these results, which invariably became the next question (Do I stop/increase/change my medication/patches/salt intake etc etc) Normal or abnormal is the answer they are trained to give, and referral to the nurse or doctor who can inform them further is absolutely the correct approach.
Faxing every one of those results to patients would be a huge waste of time and staff resource which should be employed elsewhere.
This is not the first time I have noted your disdain for the work of receps. I might suggest you spend a week doing their job and then you maight see things differently.

Sadequr Rahman

Posted: 25/05/2008 10:56:57

2) To MS - It appears you attempt to make this some 'battle of the sexes', so lets make things clear - serious thyroid diseases are not exclusively male or female, and they are treated as thoroughly as needed via surgery and radio-active iodine. These are not gentle or side-effect free, but are often life-saving. Almost always these are patients with grossly overactive thyroid.

Like most blood tests, lab ranges are taken from long-term studies of a particular population and so the definition of 'normal' will vary considerably from one country (even one county) to the next, so whatever the American ranges are is neither here nor there. As with most of these results, they will either be normal or 'slightly abnormal', the latter often seized upon by patients demanding treatment for their symptoms.

Sadequr Rahman

Posted: 25/05/2008 11:02:11

What are these symptoms? Most patients will present with feelings of tiredness, reduced sex drive, weight gain, general aches and pains, constipation. Sometimes a physical or biochemical cause can be found for these symptoms. Most of the time, the cause is purely lack of exercise, poor diet, and dissatisfaction with home/work/family life. Attempting to treat these with a tablet is mostly a waste of time. Indeed our practice has many patients on thyroxine who are in the higher band of T4/T3 level according to established ranges. Sadly, almost none of them report any improvement in their symptoms. Conclusion - doggedly treating a blood results as though they are the be-all and end-all, rather than treating the patient's actual concerns, is doomed to failure. You may not like how it's measured, but when people who have more experience than you tell you that a result is normal, sometimes you just have to accept it.

Dan Brett

Posted: 25/05/2008 11:10:50

Goodness gracious me! Is this what is meant by 'thyroid storm'...?
Please let me sincerely apologise to anyone that might have been offended by my comments. My eyes have certainly been opened to the anti-NHS views ("The NHS is killing us) on thyroid disease, held by a small minority of my medical colleagues and patient groups, on sites such as www.tpa-uk.org.uk. The opinions of the much revered Dr Barry Durrant-Peatfield and Dr. Jacob Teitelbaum are certainly interesting and thought-provoking. I, for one, will be looking more closely at my next set of 'normal' TFTs, before filing them away and I hope that this particular storm in a TFT cup now blows over...

Sadequr Rahman

Posted: 25/05/2008 11:19:19

3) to JJ - I think you'll find that male impotence is considered equally worrying for both partners, and is quite as common as the 'tired-all-the-time' consultation. Thanks to the hard work of pharmaceutical companies, many patients now demand tests for testosterone blood levels despite there being no established link between testosterone and sexual drive/function. Demand for testosterone patches and for viagra-tye medications continues to increase, despite their high cost the NHS continues to fund lifestyle drugs at the expense of other patients requiring real life-saving drugs.

Sadequr Rahman

Posted: 25/05/2008 11:19:28

You'll also find that Dr Brett cannot charge any patient who makes an appointment to see him to discuss blood results, nor can I or any other NHS GP, as you are no doubt fully aware, so you should cease this baseless accusation. He indicates that a charge for faxing pages of results around routinely would be entirely justified, not to mention issues of confidentiality. Unless I assume in the context of referring to a colleague or specialist. Again, take note of my comments to JS.

Sadequr Rahman

Posted: 25/05/2008 11:27:10

To JD - There is a real difference in showing compassion and trying to make something out of blood tests when there is nothing, which all too many patients seem to want from their doctor. If you read recent studies which show the ever increasing burden of obesity, fat middle aged men or women are far less an insensitive generalisation, rather increasingly a fact of life. Suggesting that this is due to thyroidism or any one single medical issue is blinkered and nonsensical thinking. I'm sure many who join support groups have real life issues, but perhaps those who run them should to their jobs and offer support, rather than blaming the GP because their symptoms (see above) have not magically gone away.

Sadequr Rahman

Posted: 25/05/2008 11:31:46

Finally to Dr DB - I'm sure your clinical examination and investigating skills are beyond reproach. Even when we know there's no real medical cause, they still pay us to be diplomatic. Play nice!

J Jones

Posted: 25/05/2008 15:08:29

S.R. "Even when we know there's no real medical cause, they still pay us to be diplomatic."
But that is the point S.R. You may know something about medicine from studying 1980s textbooks and passing years of multiple choice exams but there are millions of facts that you simply don't know.

You probably don't have the time or the inclination to go home every night and read the Journal of Clinical Endocrinology etc. Patients with chronic illnesses are motivated and make time to study up-to-date research about their illness because they want to get better. You could learn something new and expand your own understanding if you got over your arrogance.

Talia Newman

Posted: 25/05/2008 17:09:48

Mr S.R- Compassion is everything!Whether the blood TSH results are 'normal' or 'abnormal' at my practise makes no difference anyway.The GPs at my practise can,t even interpret them.So the preferred diagnosis is M.E,Fibromyalgia,Hypochondria or the favourite..depression.Because the clinical evidence of hypothyroidism is equally ignored it is easy to understand why this is the most frequently misdiagnosed illness of modern times.Perhaps,you think you know better and as a trained doctor thats to be expected.However,your attitude leaves a lot to be desired.If a member of your family had to endure what many badly treated thyroid patients have,you would surely feel angry on their behalf,woudn,t you?
Your comments regarding testosterone are questionable.What makes you assume they are correct?There's plenty double blind placebo controlled studies that blow your assumptions out of the water.It is all a matter of opinion and even as a doctor you sometimes have to accept this.

Mary Shomon

Posted: 25/05/2008 17:38:38

Re: TSH Worship: Lab values in the UK and the US have consistently had similar parameters, so arguing that there are different reference populations is specious. Labs in both areas have used 0.5 to 5.0 (approximate) for years. But many US endos now view levels above 3.0 as evidence of thyroid disease, and treat these levels. Peer-reviewed journal research has shown that high-normal subclinical hypothyroidism contributes to heart disease risk and infertility. TSH is known to be unreliable during pregnancy; FT4 is considered more accurate for maternal and fetal safety. There is evidence that treating high antibody levels and normal TSH may resolve symptoms and prevent progression to overt hypothyroidism. If SR and DB and their NHS colleagues are relying on TSH to the exclusion of clinical evidence and patient symptoms, shouldn't the reference range at least be reliable, and not outdated?

Mary Shomon

Posted: 25/05/2008 17:51:49

SR says that letting patients know their actual test results "would be a huge waste of time."

SR argues that thyroid problems are not predominantly female -- despite the fact that they are, by a ratio of some 7 to 1.

In terms of diagnosis, it is intellectually and professionally lazy to dismiss symptoms as due to "purely lack of exercise, poor diet, and dissatisfaction with home/work/family life" and that "attempting to treat these with a tablet is mostly a waste of time."

Dawn Wood

Posted: 26/05/2008 13:31:09

The facts are that the BTF?A have stated at a GMC hearing that they won't advise that the ref ranges for TSH tests are reduced because as thyroid patients we get free prescriptions. Is that ethical and also is it false economy and bad housekeeping given that the cost of my not being diagnosed has cost the country and the NHS approx £80k in my not being able to work so loss of my taxes, NI and now the cost of my benefit payments, endless tests, procedures and oscopies for the fall out of bladder and kidney problems, carpal tunnel, hormone related cysts etc all which would have not appeared had I been treated as soon as my symptoms presented and I had been given AI tests along with the TSH for diagnosis.

Dawn Wood

Posted: 26/05/2008 13:36:35

SR it wasn't stated that Dr Brett charged a patient however it is a fact that a patient was charged £50 for a consultaion to discuss her blood tests and it was this story that Joanne highlighted in her blog.

It is against the law to withold any data held on a person and test results are included in this however patients are battling to get hold of them and often having to resort to writing to their PCTS in order to get them.

Whether SR believes we should have them or not is irrelevant as it is our right and it is also emminently sensible that a patient should have this information particularly. when one is dealing with a number of different consultants as often tests results aren't passed on, in my case my gp doesn't pass on the results my gastro has asked him test monthly so i get them and take them to my consultation. Until the electronic system is finalised then this is a better system and gives us responsibility for our own health

Dawn Wood

Posted: 26/05/2008 13:49:07

There are many members of my support organisation who are told they are going hyper with a TSH of below 1 and have meds reduced even when they still feel very ill thus making them worse. On seeing copies of those results they find out that the TSH may be below 1 but the true test of how they are feeling, FT3 and FT4, are only just within ref range not even at the halfway mark so not going hyper and need more not less.

We would dearly love drs to treat by symptoms as you state should happen but experience tells us it does not. My job is to support my members I do not tell them Drs are rubbish etc they tell me that in posts. For the true facts then i suggest your read not the BTF site but this one www.thyroid-disease.org.uk where you'll find links to the latest papers and many patient experiences

BTW if your thyroid patients aren't getting well on just thyroid meds then maybe look at B12, folic acid, ferritin and sex hormones as well, levels drop with TD and symptoms are similar

Dawn Wood

Posted: 26/05/2008 14:37:15

On a personal note I do not and have never had a goitre it isn't a compulsary symptom. I merely had constant pain, difficulty walking, memory loss, dementia, mood swungs, early menopause, a cholesterol level of over 8, carpal tunnel, a body temp below 36.0, a 3 stone weight gain despite sword fighting once a week (real stuff not wimpy fencing) a healthy diet and the gym, hair loss, scaly skin, brittle nails among many others, couldn't work and was made bankrupt. All either disappeared or eased once on medication my cholesterol dropping to just above 5 within a week of taking it. I had a wonderful gp who felt I had TD but the local labs refused to test AI's and FT3 if I was within range and I am unfortunate enough to live in Leeds whose ref range is top end 6 so in the end I exercised my right to choose and went to a neighbouring PCT hospital with an upper limit of 4.5 and was finally treated. Postcode lottery strikes again but who gave the labs the right to diagnose

Dawn Wood

Posted: 26/05/2008 15:58:43

Could I also ask are you so disparaging of other patient support groups and conditions. For instance do you call your diabetic patients in for a cursory blood test once a year and then leave them to get on with it, dismissing them if they have done a bit of reading to help them manage it better. Do you say don't join Diabetes uk as you won't learn anything
If not them please accord us the same respect. We have worked with NHS staff from the outset on the best way to support our members and the information we give out. I never set out to create an organisation it simply happened and appalled there is such a need for it and I have been placed in this position and we have such a large dissatisfied membership who are having to resort to private tests, drs etc because they are being failed by the NHS. If Joanne's blog has done anything it has shown that we are not paranoid and that many drs do indeed treat us as if we are what the title suggests, my phrase not hers based on my observations

I D

Posted: 26/05/2008 16:39:47

Please ignore Mary Shomon. She’s just a marketer and endorser.

I don’t even believe she really has a thyroid problem. All I see a person who wanted to control her weight and feel wonderful by getting on thyroid meds (falsely thought to help with that), was told by a real dr she didn’t have a problem and then searched until she found an alternative dr willing to go along with what she wanted. She has since successfully parlayed this whole idea into selling books and doing marketing on the Internet. This is done under the guise of being a thyroid patient’s advocate and the true voice of some so-called medical conspiracy.

Thyroid is a serious medical issue; one that causes serious and heartbreaking life issues. Unfortunately, as a real thyroid patient, I know this all too well.

I D

Posted: 26/05/2008 16:47:35

The following is from a blog of an American woman writing about her own experiences. She writes:

“Do I have thyroid issues? No. I have a goiter, but year after year, my thyroid tests and biopsy tests are normal. It's funny though, I remember when someone suggested I might have thyroid trouble and that may be causing my weight gain and tiredness. I was so happy to have a reason for being fat and tired and that there might be a pill I could take to improve it all. No such luck.

I'm not taking anything away from anyone with depression or thyroid issues. They are all very real. Ultimately, it's plain and simple. I have gone through so much in my life, yet I have failed daily, to make sure I have taken the best care of myself possible, in order that I may best care for those I love.”

Don’t you wish everyone could be so honest? That is, separating weight and self-care issues from real thyroid issues. Now there’s a woman to be admired – a ‘goitre girl’ who got a life!

I D

Posted: 26/05/2008 16:51:03

If we were talking about some triviality, it wouldn’t seem so bad – but we’re not. When I first went through my own diagnosis and searched the Internet, it took me aback at first to see this issue so degraded, mostly thanks to the likes of Mary Shomon (advocate with a website that ends in .com?). Eventually, I did come across some sound information but it took work.

By the way, this person is only one example. There are others, especially with the ‘there’s a medical conspiracy out there’ and ‘your medical dr is incapable and/or unwilling to help you’ pitch. Funny, their only resolve is via something they’re involved in the sale of. Some of which not only does not work but also can be downright dangerous, especially to persons with thyroid problems.

I D

Posted: 26/05/2008 16:53:45

The other thing that’s funny is seeing Mary Shomon write ‘…Brett would have to be witty or funny to pursue a career as a comic, and as is abundantly evident, he is neither…’ Hum, it seems she would know a thing or two about comedy. Apparently she previously wrote comedy books before staring in her own ‘I’m a thyroid know-it-all’ production. Wish she’d at least gone to med school before embarking on that one.

I D

Posted: 26/05/2008 17:02:13

Luckily, I’m not the only one with a thyroid problem wishing Mary Shomon would stop invading something she’s really not a part of.

Also, I’m not alone in thinking that instead of seeing this woman pursuing the re-education of drs on what are appropriate TSH levels (by the way, American drs are in agreement with British drs), she would be better off pursuing the re-education of her own self-perception and her own mental health – some-where-else. That would be a gift to all. Plus, maybe her followers would do the same. Thus freeing up space within the area of thyroid medicine for the rest of us (most of which, frankly, don’t want to be there).

So again, I repeat, ‘Please ignore Mary Shomon.’

I know I can safely speak for all real thyroid patients, with real thyroid problems, in requesting the following:

All drs, world-wide, please don’t cave in – we need you.

Sorry to dominate but I’m sick of Mary Shomon and the like doing the same for far too long.

Thank you

Mary Shomon

Posted: 26/05/2008 17:34:09

What can one say about an anonymous poster like ID (who claims to be a patient, but whose diatribe suggests otherwise)? I'd be interested in what ID is doing to help thyroid patients.

As for me, I've spent more than a decade advocating for patients who have trouble getting diagnosed, whose doctors aren't treating them properly, or taking them seriously.

I am a thyroid patient -- Hashimoto's hypothyroidism, FYI -- who has learned the hard way how to advocate for myself. My goal is to help other patients -- wherever they are -- get the compassionate, knowledgeable thyroid care they deserve.

As for my info, it doesn't cost a thing to read the thousands of articles that I've written over more than 10 years. It's all free.

Also, ID needs to do some homework. American doctors are NOT in agreement with NHS that the old range (.5-5) is standard. The AACE advocates the range of .3 to 3 and many leading-edge US doctors have long abandoned the OLD range (that NHS uses).

Mary Shomon

Posted: 26/05/2008 17:41:47

Thankfully, our anonymous pal ID doesn't speak for any thyroid patients. Because advocating for the same-old attitudes and treatment, both in the US or in the UK, gets patients nowhere.

Thyroid patients are sick of doctors -- and patients -- who want to question the "mental health" of thyroid patients who don't feel well.

Thyroid patients are sick of doctors -- and patients -- who think that thyroid patients should be seen and not heard, and that doctors are to be worshipped, rather than partnered with.

To that end, ID is more than welcome to the doctors who think and practice like Dan Bretts, Sadequr Rahman and their ilk.

Meanwhile, those of us who want to be well are encouraged that there truly are talented, knowledgeable doctors to diagnose and treat thyroid problems. And my goal is to help my fellow patients find those docs, wherever they may be -- and to avoid the docs who view thyroid disease and patients with contempt or ignorance.

Sadequr Rahman

Posted: 26/05/2008 18:28:43

DB - I just googled Mary Shomon. I think the American term appropriate here is...BUSTED! The woman goes around writing hogwash books on 'thyroid -diets' (yes, really), basically peddling old GI -diet ideas, offering 'recipes for the under-thyroid' and showing up on every Richard-and-Judy type couch potato daytime TV shows. Check out her books on Amazon.co.uk - 100% written for the 'I'm fat but it's my glands' brigade!
JS - I wouldn't allow this charlatan to blow her trumpet on your behalf.

Mary Shomon

Posted: 26/05/2008 19:46:15

Rahman--Thyroid Diet talks about how to get thyroid disease diagnosed, and properly treated, and the role thyroid problems can play in weight. If you actually read the book, you'd find that it is not suggesting thyroid as an excuse for all weight problems. It's written for the hundreds of thousands of people in the US and the UK who are being treated by incompetent doctors who cannot recognize thyroid conditions, who don't know how to treat them when they encounter them, and who have minimal understanding of nutrition, and the connection to the endocrine system. Your patients, obviously, could clearly benefit from reading it. Sadly, you are with every post, proving exactly what the UK thyroid advocacy groups have long said: some patients in the UK are being sorely mismanaged by contemptuous, incompetent practitioners. I feel sorry for those who must rely on your for thyroid care.

Dawn Wood

Posted: 26/05/2008 20:35:45

In the character slanging match that this seems to have deteriorated into the premise behind Joanne's blog has been lost. Most comments are irrelevant to the issue as to whether it is right for a dr to charge a patient for a free consultation to discuss blood test results.
The fact that the drs here only have the defense of attack, have abused myself and a colleague as mad busy bodies for bringing this issue to light and haven't actually answered any of the questions posed as to whether it is ethical to do this, whether it is ethical to not reduce the reference ranges because it will cost the NHS too much money (despite the fact it costs the country not to diagnose), whether labs should be consitent across the country, never mind the world for now etc is more telling and I would be grateful if they would actually read my prior comments and answer them.
Patients don't want to be given thyroid meds to lose weight they want it to get well and get a life back

Dawn Wood

Posted: 26/05/2008 20:46:09

Dear ID, SR and DB I btw am not selling anything or making any money out of it. I give up my time for free, in fact it costs me to run my website and while i am doing it I can't be getting back to work so am pretty much starving (currently £2 to my name). I am a real thyroid patient and my members are all real thyroid patients who are all thankfully able to use the internet and read the medical and research papers themselves so if their gp says they can't have a trial of meds because it may damage their heart or bones can quote the relevant article that now says the opposite and state the differences in other countries. We know Dr's have to be jacks of all trades and can't know everything so please allow us to learn for ourselves and don't feel undermined when we have info to show you that you haven't had time to find and give us the respect you demand from us so we can work with you, as we don't want to self medicate and look elsewhere if we don't have to it only exacerbates the issue

Luke Koupparis

Posted: 26/05/2008 20:48:27

Reading the many posts on this subject merely confirms to me that it is quite tricky to have a sensible, scientific, evidenced based debate on a topic which is so controversial. It would seem that the differing reference ranges that exist between laboratories is confusing and should be standardised. This has been an interesting and lively discussion, but I feel we should try not to allow emotions to colour our judgement. As with many areas of medicine, there are grey areas where there is no strict right or wrong. I personally would feel a failure if I missed a diagnosis of hypothyroidism with some of the classical symptoms described. I am sure that this will be the case for most GPs across the UK. In keeping with this, it would be very uncommon to find any UK GP who would make a charge for a simple printout of blood test results.

Geoff Nicholson

Posted: 28/05/2008 08:22:54

I'm a bit bemused by this blog. Some good points made that equally well be made without descending into personal abuse. As a GP I find interpreting blood results a real challenge that I was not prepared for at all at medical school. 1 in 20 of all results are going to be abnormal by definitiion. On the borderline, sometimes my hypothesis will be wrong, sometimes the patient will be wrong, sometimes we will both be wrong.

The longer I'm in practice, the more I realise it's wise to respect other peoples point of view, even when I don't share it.
Geoff Nicholson, GP, fat bloke, euthyroid (as far as i know!!)

Simon Waters

Posted: 31/05/2008 22:27:38

"Suggesting that this is due to thyroidism or any one single medical issue is blinkered and nonsensical thinking."

Agreed for the general case. No one ever got obese without eating more than their metabolism burns off.

There are good studies showing that obesity is much more common in treated hypothyroidism (normal TSH) than it is in the general population. This excess in obesity isn't found in those treated for thyroid cancer with TSH suppressing doses of levothyroxine.

So clearly normalizing TSH doesn't represent a level of thyroid supplementation that alleviates all the metabolic issues of hypothyroidism, at least for a large proportion (~20%) of hypothyroid patients (the proportion representing the excess of obesity over the general population).

No doubt all these obese thyroid patients eat more than their metabolism burns off, but nearly half of them wouldn't be obese if they didn't have a thyroid problem.

It raises an interesting question about what is the appropriate dosing of levothyroxine. Normalizing TSH has become a mantra, and as a first step in treating symptoms it is probably a sensible way to proceed. But if your treatment of hypothyroidism always stop there you are following a dogma and convention, and ignoring what the science is telling us, and probably leaving patients with symptoms that might be alleviated with a little effort on the doctors part.

Dawn Prince

Posted: 01/06/2008 11:20:57

I am hypothyroid and have suffered for years for the very things that head this blog. Doctors and care givers please listen to your patients because the TSH is not the be-all and end-all of how we are doing, it is only the first indication that you look at. What I have found while going through this nightmare is that Synthroid etc: is not always the answer and other things must be added or changed due to the fact that when the thyroid no longer functions as it was made to, then other parts of our system breaks down. When we are left to stay for years with never being able to lose weight, forgetting what we are in the midst of saying, not being able to sleep a full 8 hours or sleeping for 18 and still being so bone weary as to not be able to get out of bed. Diets, we have tried them all and they dont work for us and when our doctors look at us with disdain because of this it only adds to how we feel about ourselves.

Dawn Prince

Posted: 01/06/2008 11:31:39

contd:
This is a very debilitating condition and should be treated as such and we should not be rediculed for being sick, I thought that we were way past those days. When you are presented with a patient that has a malaise that you fail to find a cause for through normal tests instead of just handing out anti-depressants, diet pills and sending to physics please go through thyroid tests even if the TSH says normal. That is only the designation of the labs and has little to do with how the body is in fact metabolising or not the T4. When it is not then we have all these symptoms and they are real not in our heads. I know from experience that synthetic T4 is not good for me because I could not process it and it caused many other conditions that required me to daily take 10-12 different kinds of meds. Since my doctor changed my meds I am now only on one other med beside my thyroid meds.

Dawn Prince

Posted: 01/06/2008 11:42:02

I was very lucky and my doctor listened to me and we discussed and came to a joint conclusion on how to treat my condition. That is what being a doctor is all about, listening to us and actualling hearing what we are saying and then coming to decisions on the best procedure to follow. Not only am I a patient I am also a moderator of a large thyroid support group with over 2,000 members so I have heard it all before, but this was the first time that I heard it from a doctor in this manner. I truly hope and pray that you will be learning from all of this furor that you have created. We are patients that are really sick and we desperately need your help and support and I appeal to all of you to help those that are suffering in this manner and stop labeling us as you have been doing in the past. Thank you for reading my post.

Frances Davis

Posted: 02/06/2008 23:10:51

I violently object to the attitudes posed here by Brett and other so called medics on the suffering of Thyroid Patients
The ridiculous assumption that all the women are simply Mad /fat and Meniopausal is totally insulting and totally wrong
Of course there will be a minority of deluded patients but the main deficiency is in Thyroid Tests and the crazy figures placed on so called "normal " values in the UK
Add that to the fact that its now well documented and researched by a team in Bristol that Thyroxine does not work in a proportion of patients
There are also many Men who most definitely are not Mad or fat or Menopausal who go through hell with Thyroid Disease and often have no option but to retire early much to the detriment of their family

I sure know several who suffered the full gamut of hypo symptoms even into Myxodeama madness yet had a TSH of 2.5 and free T4 of 19

Luke Koupparis

Posted: 03/06/2008 11:06:07

Frances, thank you for your post. Are you saying that a patient can have severe hypothyroidism, even myxoedema, with completely normal thyroid function tests?

Frances Davis

Posted: 04/06/2008 03:01:26

ABSOLUTELY ...research in Sweden years back proved that patients who have had Graves Disease (Hyperthyroid) or severe Graves episodes of Hashis are sensitised to extremely high levels of Thyroid Hormones thus when a sub total thyroidectomy is done or the Hashis burns out the normal blood test levels which Doctors are slaves to have no meaning
Add on that years of sliding into Hypothyroid causes damage to the receptors and causes ragged red muscle fibres and you have patients who do not fully recover
Many patients cannot tolerate Thyroxine or T3 because of its fillers and its synthetic and they have become chemically allergic .........hence these are the patients who desperately need natural Armour Thyroid
The research in Bristol is now to study the particular Genetic link this group of patients belong too because while some Thyroid patients are quickly diagnosed and easily treated using Thyroxine there are others who can only be treated on Symptoms not on blood tests results

Frances Davis

Posted: 04/06/2008 03:13:41

and yes I can provide proof of patients who have endured all of the above and have had their lives wrecked and are only now halfway well and able to function thanks to Armour Thyroid
There is also proof that despite always eating a balanced diet full of fruit and veg etc before their Hypothyroidism was diagnosed they had severe vitamin B and C deficiencies because the sheer toll thyroid disease makes on the body seriously depletes vitamin and mineral stores
Never in their lives have they overeaten and their diets are considered to be so healthy they should be glowing with health

What is taught about Thyroid in medical schools etc is fatally flawed and only a very few open minded Doctors have faced this reality and have been prepared to actually listen to patients and try to help them much to the annoyance of a large swathe of Endocrinologists

Dan Brett

Posted: 04/06/2008 08:49:49

My final word(s) on this subject (maybe...!) are actually from the British Thyroid Association: "Warning! There are a number of websites with unhelpful and inaccurate information about thyroid disease which should be ignored. Our links are for recognised patient support and information sites recommended by the BTA. The BTA is the only national professional organisation in the UK composed of research doctors and consultants who are accredited by having completed higher professional training in thyroid and other endocrine diseases."
Also read this helpful statement on Armour Thyroid on the following link:
http://www.british-thyroid-association.org/armour_statement_2007.pdf
Armour thyroid - made from the same pigs that might fly before I change my clinical practice on the advice of the charlatans comments above...

Luke Koupparis

Posted: 04/06/2008 09:13:54

Just to reiterate another important point on Armour thyroid. Advice from the BTA is that the amount of thyroid hormone is more variable between batches than it is in thyroxine tablets, and it contains potentially harmful levels of T3. So it is not licensed in the UK and can potentially be dangerous if taken...I will not be using this in my clinical practice.

Frances Davis

Posted: 04/06/2008 09:43:14

Sorry but Patients who are on Armour Thyroid do not experience variability between batches .........what they experience is a life worth living as opposed to one full of horrendous aches and pains and other debilitating symptoms for which doctors have absolutely no answer

Before Thyroxine was grandfathered in to medicine without any proper testing Natural Thyroid Hormone made in the UK was the normal treatment for hypothyroid ......only because of a rogue batch which did indeed cause problems was it pushed out in favour of synthetic thyroxine

If you actually lived with a Thyroid patient who had experienced the full gamut of thyroid disease over 40 + years and the damage it had reeked along with the hell on Thyroxine you would know the truth of the difference Armour makes

The BTA have a vested interest in slamming anything but their dogma that Thyroxine is perfect ..........sadly for some patients its anything but

Frances Davis

Posted: 04/06/2008 12:09:58

Thalidomide was licensed
Cox2 Inhibitors were licensed
Prozac was licensed

The problems and damage done by those and many other so called tested and licensed drugs is well documented

How many Doctors happily prescribed them ?

My Mother died from stroke damage as a result of being prescribed Cox 2 Inhibitors ..........but in the UK unlike the USA we cant sue the manufacturers for that mess ...and the doctors argued black was white was purple that her 1st strokes were merely stomach upsets
The paramedics and myself knew very well that loosing conciousness , vomiting , almost undetectable BP and a loss of bladder and bowel control was the result of strokes not a stomach upset from food that 10 other family members all ate without incident

Sheila Turner

Posted: 04/06/2008 12:12:36

As Dan and Luke have read the BTA Statements on Armour and synthetic T4/T3 combination therapy, perhaps they would also read the response from TPA-UK by way of correcting the BTA's misleading, and in parts, incorrect statements. * http://www.tpa-uk.org.uk/resp_bta_armour.pdf * and * http://www.tpa-uk.org.uk/resp_bta_t4t3.pdf *. Just copy and paste into your search engine. Keep an open mind Dan and Luke, read ALL the facts...and to Luke, the T4/T3 IS standardised in every tablet. Do you believe the MHRA would allow it to be prescribed if this was not the case? Armour new drugs licensing procedure because of past potency problems. Thyroid extract has been used safely and effectively for over 100 yrs and was the ONLY medication for hypothyroidism before synthetic T4...and btw, yes Luke, patients can and do suffer hypothyroidism with normal TFT's. This is the controversy!

Sheila Turner

Posted: 04/06/2008 12:24:17

The previous message should NOT have read - Armour new drugs licensing procedure etc....it should have read - Armour has never required to be licensed under the new drugs licensing procedure, unlike L-thyroxine which had to be licensed because of past potency problems".

Sheila Turner

Posted: 04/06/2008 13:21:34

In a survey of 1500 hypothyroid patients undertaken in the UK in 2005-2006, the dissatisfaction of many patients is highlighted. Of 1500 respondents, 93.8% (n=1407) had not been told of medicines other than L-thyroxine by their medical practitioner. 38.8% (n=768) felt they had "not been dealt with very well" or "not very well at all" by their doctor whilst seeking a diagnosis of their symptoms; 233 (15.5%) had given up paid employment; 300 (20%) had taken time off work as a result of thyroid illness; 500 (33.3%) felt their close relationships had been affected by thyroid illness and 632 (42.1%) had stopped or altered their exercise routines as a result of their symptoms. When asked of those patients undergoing L-thyroxine therapy "Do you feel that you have fully regained your optimal state of health", a staggering 1176 (78.4%) Answered "No"

Sheila Turner

Posted: 04/06/2008 16:56:12

To Dan, Luke,Sadequr, ID, JJ, Geoff, if you really do care, and I am sure you do, read comments by patients on the International Hypothyroid Patients’ Petition for Better Diagnosis and Treatment Choice for Hypothyroid Patients "http://intlhormonesociety.org/index.php?option=com_content&task=view&id=31&ItmHack_idp=10"

To quote one patient: “The ignorance, arrogance and incomprehension of the medical doctors I have been subjected to in my search for diagnosis and treatment leaves me incandescent with rage. Even as a qualified health professional working for a major DGH I remain powerless to prevent the cumulative long term health risks associated with lack of treatment; I am voiceless, neutered, patronised, and crawling day-to-day through what used to be my vital and colourful life. I would give everything I have for an open minded and creative diagnostician, and more for a little compassion, but this seems to be entirely beyond the capability of the modern medic. God help us all.”

Dawn Prince

Posted: 05/06/2008 23:48:30

I always thought that medicine was an ongoing learning experience but when minds are closed to what others have to say and can only resort to name calling others who differ in their opinion/experience then medicine is going back to the dark ages. Medicine is said to be a "practice" implying that it is an ongoing learning for those that are willing to learn. From what I have read here it seems that there are few that are willing to stretch their minds to other possibilities of how people can be helped. God did not make us from a cookie cutter and one size does not fit all and therefore we are all in dire need of being treated according to how our bodies function not as to how someone in a lab thinks it should be. A good and I stress the word "good" doctor will be willing to work with his patient to attain the best possible outcome for them even if it means they have to leave their preconceived ideas behind and go into a realm where they are not so comfortable.

Dawn Prince

Posted: 06/06/2008 00:03:56

After all it is the patients life that is being messed with and when a doctor does not do all that he/she can to help the patient then they are not bearing in mind the hypocratic oath. By doing nothing or insisting that your way is the only way then you are doing your patient harm. Also remember that you are employed by the patient even if you are not physically being given the cash it comes out of their pocket one way or another in the form of taxes. Think about this if your pay depended on how happy your patient was with your performance how rich would you be? I suspect that many of you would be on the bread line as people would not be paying for the performance that I have seen here. I remember doctors so concerned about my health that they would come to my home and sit by my bed for as long as it took for them to be assured that I would be alright. Thyroid patients deserve better from the medical community, would you treat your mother like this?

Dan Brett

Posted: 07/06/2008 12:33:16

Ms Price - With your references to 'god', 'cookie cutters' and being 'messed with', can we deduce that you are from the good old U S of A? Perhaps you should focus your attentions on the problems with the American healthcare system. On this side of the pond our way of working is not unlike the lyrics of this Rolling Stones classic ( - and if you're bringing mothers into it, this is one of her favourites! ) - "You can't always get what you want... But if you try sometimes you just might find... You get what you need"...

Dawn Wood

Posted: 07/06/2008 15:02:58

To LK your definition of normal tests is the crux of this discussion and the problems with diagnosis. In many countries a TSH of 2.5 would be the top end of the ref range and treatable with a diagnosis of hypothyroid. As I highlighted in an earlier post the BTA/F have refused to advise the reduction of the range in this country, contrary to current research, due to cost issues. I note Dr Brett hasn't responded to this comment re the ethics of this decision. The survey Mrs Turner mentions, which I wrote in 2005, is also backed up by a government PatientView survey which shows a higher proportion of those with thyroid disease felt they had a lower QOL than those with other LTC's. The BTF/A website falls to mention the product withdrawals by the FDA of thyroxine and the continued problems it has with stability. Armour thyroid's recent recalls were by it's manufacturer on tablets which were due to expire within a couple of months and not by the FDA.

Dawn Wood

Posted: 07/06/2008 15:03:02

Dawn Wood

Posted: 07/06/2008 15:11:12

With ref to the BTA's warning re internet groups Dr Brett may like to know that the 2 ladies mentioned in Joanne's blog have advised on the guidelines for the DOH accreditation scheme so hardly misinformed and I would like to thank him for inspiring 2 new t shirts to add to our collection, we have sold a few already and the royalities will be spent on giving up to date information to both drs and patients which we will happily send him for free http://thyroid-disease.spreadshirt.net/en/GB/Shop/

Sheila Turner

Posted: 08/06/2008 10:59:46

A message to Frances Davis :

Please would you contact me as a matter of urgency at sheilaturner@tpa-uk.org.uk

Many thanks

Sheila

Sheila Turner

Posted: 08/06/2008 12:58:57

Dan, I would like to thank you for highlighting what is well known as a worldwide scandal. The more like-minded, and positive, people publicise this issue, the more hope we have for progress to be made in securing a long overdue ‘proper’ protocol for the diagnosis and treatment of hypothyroidism.

Dawn (Wood), regrettably, you have still not learned the difference between "writing" and "editing". You have simply edited written material provided by others and a medical practitioner working in the field of thyroid disease prior to publication. This blog is highlighting the problems hypothyroid sufferers have with some NHS doctors. If you have issues in connection with who "wrote" the survey, please feel free to get in touch with me direct. Wandering off down side streets to broadcast what you perceive to be a personal grievance is an unhelpful distraction and not what this blog is about.

Dawn Prince

Posted: 08/06/2008 21:15:06

Dan: #1 Name is PRINCE. #2 Born in Hants UK lived there for almost 30yrs now live in Canada where we have "universal healthcare". I do understand your system but not the attitude which seems to be worldwide that thyroid conditions are not to be taken seriously until we are at deaths door. Our range here is .3-3. but is being looked at reducing to .3-2.5 according to the latest research. At 10 your range is way to high and is causing your patients untold misery and no life. As to what we need: we need doctors that care about us and who is not so closed minded that they will not even check out the latest research that is being done. I also think that the system in the States needs to be addressed too as I know of many whose lives have been ruined by doctors that didn't care enough and they ended up in storm and almost died.

Dawn Prince

Posted: 08/06/2008 21:24:12

I am very familiar with the health systems in Uk, USA and Canada and sorry to have to say non are perfect but at least the doctors that I have been to in this country do a pretty good job. Please for the sake of your patients get off your high horse and learn what we as patients are trying to tell you so that we can have a relatively normal life. Live in our shoes for one month and you would soon change your attitude. You may have an MD behind your name but if you are not willing to work with your patients and you expect them to think of you as the great Lord of medicine then may I suggest that you re-think your profession. Or how revolutionary become an advocate for us and work on our behalf to get things changed for the better.

Sheila Turner

Posted: 09/06/2008 08:48:35

Dan, When you wrote above "...The opinions of the much revered Dr Barry Durrant-Peatfield and Dr. Jacob Teitelbaum are certainly interesting and thought-provoking. I, for one, will be looking more closely at my next set of 'normal' TFTs, before filing them away... " Do you REALLY mean this, or is your tongue stuck in your cheek? If this 'storm in a teacup" as you put it, has done nothing else but made just one doctor look at this problem with the seriousness it deserves, then this is an enormous achievement. Dawn (Prince) your sister may need to join the ever growing band of patients who are being forced into self medicating because the BTA are giving out misleading and incorrect information about the treatment of hypothyroidism. She is probably suffering the pains of fibromyalgia which is treatable with the thyroid hormone T3 . See Dr Lowe's critique of the 4 studies into combination therapy (2003) http://www.drlowe.com/frf/t4replacement/intro.htm

James Dick

Posted: 18/06/2008 05:45:01

As a male who is Hypothyroid . I thought that I would like to add that much of the above applies to us males as well. I am a Biomedical Scientist and much of this discussion has been educational.
When I was originally diagnosed my TSH and FT4 were normal even on repeat after 3months, but my GP was not convinced as I had all symptoms-putting on weight,low energy levels,falling asleep at work,memory loss, skin rashes which did not respond to cream etc.
So we sent my blood for Thyroid Ab's. My ATPO was >1000.
I have had to up my thyroxine twice in the last two years. Initially I was monitored every 3months this was reduced to every 6months which failed to pick up my last increase in TSH level and I had to request a check as I was feeling tired. Thyroxine has not cured some of my other troubles.
I am also still having trouble keeping my weight down. Untill 2000 I was a keen runner now I get breathless after 0.5miles (I also got asthma following the virus which triggered all this) etc.

Dawn Prince

Posted: 18/06/2008 12:44:13

Hi Dick,
It is possible that your body is not converting the synthetic t4 in thyroxine, I had the same problem at one time. I have now switched to the old fashioned Armour or in Canada Thyroid which is the pig/cow thyroid gland which has all of the t's in it. Your tsh or free t4 will never show this problem as there will always be enough of the t4 in the blood, while your body is starving for the free t3 which you need for the energy etc. So you may want to get a test for free t3 as well, to see how that is doing and it should read in the higher end of the range. Conversion of t4 to t3 etc. seems to be a very common problem with those of us with hypo and it is rarely recognised by the doctors. The other alternative is to take the t3 added to your levothyroxine. So there are other avenues for you to explore and I wish you well as you do so.

Bridget Harris

Posted: 12/06/2009 12:15:54

Lest misinformation mentioned above get falsely thought to be true…

To date, the current TSH range recommended by the AACE does ‘not’ get employed by most reputable U.S. doctors and labs. The AACE makes a recommendation - not a mandate!

Also, the AACE recommendation suggests that any TSH reading above their highest number should prompt a consideration of treatment - which is different from giving a directive for treatment.

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Joanne Shaw

Joanne sits on the boards of various health care organisations including: ‘Ask About Medicines’, the independent campaign to increase people's involvement in decisions about their use of medicines; NHS Direct; the Long-Term Conditions Alliance; and Datapharm Communications, which provides medicines information to the NHS, the pharmaceutical industry and the general public. She has an interest in medicine-taking and in shared decision making between patients and health professionals, and writes occasionally for medical, nursing and pharmacy publications. The views expressed in her blog are very definitely personal and cannot be blamed on any of the organisations with which she works.

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Comments [69]

Dan Brett Posted: 22/05/2008 12:06:28

J Jones Posted: 23/05/2008 01:27:18

J Jones Posted: 23/05/2008 02:11:22

Dan Brett Posted: 23/05/2008 07:38:34

John Squire Posted: 23/05/2008 11:45:40

Mary Shomon Posted: 23/05/2008 16:47:22

Talia Newman Posted: 23/05/2008 16:58:39

Mary Shomon Posted: 23/05/2008 17:17:23

Sadequr Rahman Posted: 25/05/2008 10:40:52

Sadequr Rahman Posted: 25/05/2008 10:41:05

Sadequr Rahman Posted: 25/05/2008 10:56:57

Sadequr Rahman Posted: 25/05/2008 11:02:11

Dan Brett Posted: 25/05/2008 11:10:50

Sadequr Rahman Posted: 25/05/2008 11:19:19

Sadequr Rahman Posted: 25/05/2008 11:19:28

Sadequr Rahman Posted: 25/05/2008 11:27:10

Sadequr Rahman Posted: 25/05/2008 11:31:46

J Jones Posted: 25/05/2008 15:08:29

Talia Newman Posted: 25/05/2008 17:09:48

Mary Shomon Posted: 25/05/2008 17:38:38

Mary Shomon Posted: 25/05/2008 17:51:49

Dawn Wood Posted: 26/05/2008 13:31:09

Dawn Wood Posted: 26/05/2008 13:36:35

Dawn Wood Posted: 26/05/2008 13:49:07

Dawn Wood Posted: 26/05/2008 14:37:15

Dawn Wood Posted: 26/05/2008 15:58:43

I D Posted: 26/05/2008 16:39:47

I D Posted: 26/05/2008 16:47:35

I D Posted: 26/05/2008 16:51:03

I D Posted: 26/05/2008 16:53:45

I D Posted: 26/05/2008 17:02:13

Mary Shomon Posted: 26/05/2008 17:34:09

Mary Shomon Posted: 26/05/2008 17:41:47

Sadequr Rahman Posted: 26/05/2008 18:28:43

Mary Shomon Posted: 26/05/2008 19:46:15

Dawn Wood Posted: 26/05/2008 20:35:45

Dawn Wood Posted: 26/05/2008 20:46:09

Luke Koupparis Posted: 26/05/2008 20:48:27

Geoff Nicholson Posted: 28/05/2008 08:22:54

Simon Waters Posted: 31/05/2008 22:27:38

Dawn Prince Posted: 01/06/2008 11:20:57

Dawn Prince Posted: 01/06/2008 11:31:39

Dawn Prince Posted: 01/06/2008 11:42:02

Frances Davis Posted: 02/06/2008 23:10:51

Luke Koupparis Posted: 03/06/2008 11:06:07

Frances Davis Posted: 04/06/2008 03:01:26

Frances Davis Posted: 04/06/2008 03:13:41

Dan Brett Posted: 04/06/2008 08:49:49

Luke Koupparis Posted: 04/06/2008 09:13:54

Frances Davis Posted: 04/06/2008 09:43:14

Frances Davis Posted: 04/06/2008 12:09:58

Sheila Turner Posted: 04/06/2008 12:12:36

Sheila Turner Posted: 04/06/2008 12:24:17

Sheila Turner Posted: 04/06/2008 13:21:34

Sheila Turner Posted: 04/06/2008 16:56:12

Dawn Prince Posted: 05/06/2008 23:48:30

Dawn Prince Posted: 06/06/2008 00:03:56

Dan Brett Posted: 07/06/2008 12:33:16

Dawn Wood Posted: 07/06/2008 15:02:58

Dawn Wood Posted: 07/06/2008 15:03:02

Dawn Wood Posted: 07/06/2008 15:11:12

Sheila Turner Posted: 08/06/2008 10:59:46

Sheila Turner Posted: 08/06/2008 12:58:57

Dawn Prince Posted: 08/06/2008 21:15:06

Dawn Prince Posted: 08/06/2008 21:24:12

Sheila Turner Posted: 09/06/2008 08:48:35

James Dick Posted: 18/06/2008 05:45:01

Dawn Prince Posted: 18/06/2008 12:44:13

Bridget Harris Posted: 12/06/2009 12:15:54

Joanne Shaw

Dan Brett

Posted: 22/05/2008 12:06:28

J Jones

Posted: 23/05/2008 01:27:18

J Jones

Posted: 23/05/2008 02:11:22

Dan Brett

Posted: 23/05/2008 07:38:34

John Squire

Posted: 23/05/2008 11:45:40

Mary Shomon

Posted: 23/05/2008 16:47:22

Talia Newman

Posted: 23/05/2008 16:58:39

Mary Shomon

Posted: 23/05/2008 17:17:23

Sadequr Rahman

Posted: 25/05/2008 10:40:52

Sadequr Rahman

Posted: 25/05/2008 10:41:05

Sadequr Rahman

Posted: 25/05/2008 10:56:57

Sadequr Rahman

Posted: 25/05/2008 11:02:11

Dan Brett

Posted: 25/05/2008 11:10:50

Sadequr Rahman

Posted: 25/05/2008 11:19:19

Sadequr Rahman

Posted: 25/05/2008 11:19:28

Sadequr Rahman

Posted: 25/05/2008 11:27:10

Sadequr Rahman

Posted: 25/05/2008 11:31:46

J Jones

Posted: 25/05/2008 15:08:29

Talia Newman

Posted: 25/05/2008 17:09:48

Mary Shomon

Posted: 25/05/2008 17:38:38

Mary Shomon

Posted: 25/05/2008 17:51:49

Dawn Wood

Posted: 26/05/2008 13:31:09

Dawn Wood

Posted: 26/05/2008 13:36:35

Dawn Wood

Posted: 26/05/2008 13:49:07

Dawn Wood

Posted: 26/05/2008 14:37:15

Dawn Wood

Posted: 26/05/2008 15:58:43

I D

Posted: 26/05/2008 16:39:47

I D

Posted: 26/05/2008 16:47:35

I D

Posted: 26/05/2008 16:51:03

I D

Posted: 26/05/2008 16:53:45

I D

Posted: 26/05/2008 17:02:13

Mary Shomon

Posted: 26/05/2008 17:34:09

Mary Shomon

Posted: 26/05/2008 17:41:47

Sadequr Rahman

Posted: 26/05/2008 18:28:43

Mary Shomon

Posted: 26/05/2008 19:46:15

Dawn Wood

Posted: 26/05/2008 20:35:45

Dawn Wood

Posted: 26/05/2008 20:46:09

Luke Koupparis

Posted: 26/05/2008 20:48:27

Geoff Nicholson

Posted: 28/05/2008 08:22:54

Simon Waters

Posted: 31/05/2008 22:27:38

Dawn Prince

Posted: 01/06/2008 11:20:57

Dawn Prince

Posted: 01/06/2008 11:31:39

Dawn Prince

Posted: 01/06/2008 11:42:02

Frances Davis

Posted: 02/06/2008 23:10:51

Luke Koupparis

Posted: 03/06/2008 11:06:07

Frances Davis

Posted: 04/06/2008 03:01:26

Frances Davis

Posted: 04/06/2008 03:13:41

Dan Brett

Posted: 04/06/2008 08:49:49

Luke Koupparis

Posted: 04/06/2008 09:13:54

Frances Davis

Posted: 04/06/2008 09:43:14

Frances Davis

Posted: 04/06/2008 12:09:58

Sheila Turner

Posted: 04/06/2008 12:12:36

Sheila Turner

Posted: 04/06/2008 12:24:17

Sheila Turner

Posted: 04/06/2008 13:21:34

Sheila Turner

Posted: 04/06/2008 16:56:12

Dawn Prince

Posted: 05/06/2008 23:48:30

Dawn Prince

Posted: 06/06/2008 00:03:56

Dan Brett

Posted: 07/06/2008 12:33:16

Dawn Wood

Posted: 07/06/2008 15:02:58

Dawn Wood

Posted: 07/06/2008 15:03:02

Dawn Wood

Posted: 07/06/2008 15:11:12

Sheila Turner

Posted: 08/06/2008 10:59:46

Sheila Turner

Posted: 08/06/2008 12:58:57

Dawn Prince

Posted: 08/06/2008 21:15:06

Dawn Prince

Posted: 08/06/2008 21:24:12

Sheila Turner

Posted: 09/06/2008 08:48:35

James Dick

Posted: 18/06/2008 05:45:01

Dawn Prince

Posted: 18/06/2008 12:44:13

Bridget Harris

Posted: 12/06/2009 12:15:54