Tag: comment

Functional hypoglycaemia postulated as cause of chronic fatigue syndrome

Comment on: The chronic fatigue syndrome: what do we know? [BMJ. 1993]

 

Editor,-In discussing the various causes of the chronic fatigue syndrome P K Thomas fails to mention one syndrome-namely, functional hypoglycaemia. We do not believe that such a syndrome exists, but in the Netherlands it has become a popular diagnosis among “alternative doctors,” who claim that chronic fatigue is caused by inappropriately increased postprandial insulin concentrations with subsequent hypoglycaemia. This disease is linked to a so called allergy to endogenous glucose.

It is clear from this description that there is no scientific basis for this syndrome, and this is confirmed in the literature. Unfortunately, doctors and dietitians who recognise this syndrome have burdened their patients with complicated diets, requiring the elimination of all simple carbohydrates. When we asked an alternative doctor why we never see hypoglycaemia in these patients we were told that we do not measure glucose concentrations at the right moment. The diagnosis should be made after a standard oral glucose tolerance test with measurement of glucose concentrations three and five hours after glucose intake. “Overproduction” of insulin is thus shown by reactive hypoglycaemia.

The use of this non-physiological test to diagnose this syndrome has no scientific basis whatsoever. Nevertheless, tens of thousands of patients are treated for this syndrome in the Netherlands.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1678679/pdf/bmj00039-0047a.pdf

 

Source: Heuft L, Bravenboer B, Ziekenhuis C. Functional hypoglycaemia postulated as cause of chronic fatigue syndrome. BMJ. 1993 Sep 18;307(6906):735. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1678679/

 

Chronic fatigue syndrome

Comment on: The chronic fatigue syndrome: what do we know? [BMJ. 1993]

 

Editor,-In P K Thomas’s succinct review of chronic fatigue syndrome, the extensive morbidity, misery, and misinformation that exists around this subject is not stated. The present situation is also not helped by the majority of medical practitioners having no education in, and little experience of, managing this common disorder.

Irrespective of the cause or the emotional response this syndrome produces in professionals, it creates considerable disability in our communities. The overall prevalence of people who suffer with intrusive fatigue is estimated at 150 000. Many of these (as yet unmeasured) are debilitated to such an extent that they are unable to work and are dependent on carers. It is interesting to note that within the NHS there is at the moment no single unit dedicated or equipped to assess, treat, and provide long term support for such patients. Limited facilities have been provided in beds that are earmarked for other disorders.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1678593/pdf/bmj00032-0058b.pdf

 

Source: Cox DL, Findley LJ. Chronic fatigue syndrome. BMJ. 1993 Jul 31;307(6899):328. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1678593/

 

Insomnia in the chronic fatigue syndrome

Editor,-Iain Duncan is mistaken in his assertion that the results of our study of patients with the chronic fatigue syndrome can be explained by daytime dozing. According to data from the diaries kept by the subjects in the study, the patients with the chronic fatigue syndrome slept for a mean of 11 minutes during the day and the healthy controls for 0 minutes. There was no association between either the time spent asleep or the time spent resting in bed during the day and the presence of any sleep disorder (or the time spent awake after the onset of sleep at night) in the patients with the chronic fatigue syndrome or the normal controls. Furthermore, in the few patients with the syndrome who wore their polysomnograph for the whole 24 hours there was no association between time spent asleep during the day and the time spent awake after the onset of sleep.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1678179/pdf/bmj00031-0056a.pdf

 

Source: Morriss R. Insomnia in the chronic fatigue syndrome. BMJ. 1993 Jul 24;307(6898):264. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1678179/

 

Disagreeing on how to treat CFS patients

Comment on: Chronic fatigue syndrome. A fresh look at an old problem. [Can Fam Physician. 1993]

 

There are some unfortunate inaccuracies in the article “Chronic Fatigue Syndrome.”‘ While the general information is useful in a very basic sense, two of the so-called “fresh look” items are inaccurate and misleading.

First, Dr McSherry suggests that “Oral magnesium supplements are indicated for CFS patients with subnormal red blood cell magnesium levels….” Presumably this recommendation comes from Dr McSherry’s reference to the study done by Cox et al. In this paper, red blood cell magnesium levels were found to be lower in patients diagnosed with chronic fatigue syndrome (CFS) than in a matched normal group, and patients were found to improve with intramuscular injections of 50% magnesium sulphate (1 g in 2 mL) every week for 6 weeks. However, oral magnesium has not been tested for its effectiveness in patients with CFS. Dr McSherry’s recommendation to use oral magnesium is, therefore, inaccurate and misleading.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379656/pdf/canfamphys00111-0026b.pdf

 

Source: Leyton E. Disagreeing on how to treat CFS patients. Can Fam Physician. 1993 May;39:1022-4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379656/

 

Taking exception to chronic fatigue syndrome prevalence findings by Price, et al.

Comment on: Estimating the prevalence of chronic fatigue syndrome and associated symptoms in the community. [Public Health Rep. 1992]

 

We would like to address some serious methodological issues in the article, “Estimating the Prevalence of Chronic Fatigue Syndrome and Associated Symptoms in the Community,” by Rumi K. Price, et al., published in the September-October issue of Public Health Reports. We believe that because of the deficiencies in the design of this research, the authors’ conclusions are totally illogical and invalid.

In this article, the authors conclude that Chronic Fatigue Syndrome (CFS), as defined by the Centers for Disease Control (CDC) Diagnostic Criteria, might be “quite rare” in the general population, as only 1 of 13,538 individuals studied was deemed to have CFS. The official CDC Diagnostic Criteria, however, were not utilized to diagnose cases of CFS. Instead, the researchers reviewed interview questionnaire data collected between 1981 and 1984 for a purpose unrelated to diagnosing CFS. In fact, the CDC Diagnostic Criteria were not formulated and published until 1988.

You can read the rest of this comment as well as the rely from the authors here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1403345/pdf/pubhealthrep00069-0137c.pdf

 

Source: Robin R, Lipkin DM, Hume GW. Taking exception to chronic fatigue syndrome prevalence findings by Price, et al. Public Health Rep. 1993 Jan-Feb;108(1):135-7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1403345/

 

Fluctuations in perceived energy and mood among patients with chronic fatigue syndrome

Comment in: Fluctuations in perceived energy and mood among patients with chronic fatigue syndrome. [J R Soc Med. 1992]

Comment on: Fluctuations in perceived energy and mood among patients with chronic fatigue syndrome. [J R Soc Med. 1992]

 

I find it surprising that Wood et al. (April 992 JRSM, p 195) no longer appear to consider,that the presence of a precipitating infection should be necessary for the selection of patients involved in the study of chronic fatigue syndromes. The reference they quote, which refers to guidelines laid down at Oxford in 1990, states very clearly that post-infectious patients with chronic fatigue do indeed form a distinct subgroup, and that to fulfil research criteria there, must be,’definite evidence of infection at onset or presentation’.

Having failed to make such a distinction it is not, altogether surprising that they go on to conclude that the higher levels of depression found in their study …. serve to reinforce the now widely–current, notion that such patients may be suffering from a depressive illness, of which physical fatigue is a somatic manifestation’.

You may read the rest of this comment as well as the author’s response here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293670/pdf/jrsocmed00107-0092b.pdf

 

Source: Shepherd C. Fluctuations in perceived energy and mood among patients with chronic fatigue syndrome. J R Soc Med. 1992 Sep;85(9):588. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293670/

 

Chronic fatigue syndrome and heterogeneity

Comment on: The measurement of fatigue and chronic fatigue syndrome. [J R Soc Med. 1992]

 

One thing which hampers medical research is a frustrating tendency for researchers to conclude that heterogeneous groups are homogeneous. Several examples can be cited including research into sudden infant death syndrome. In his editorial on chronic fatigue syndrome (CFS) Wessely (April 1992 JRSM, p 189) asserts that previous views suggesting CFS to be simply a form of somatized depression are no longer tenable because of one published and one unpublished study showing biological differences from major depression. This view is just as untenable as the notion that all CFS is depression. Surely the most likely explanation is that CFS represents a heterogeneous group. The notion that one or two positive findings exclude all other explanations is a dangerous one. Aside from the fact that it negates the possibility of heterogeneity it may have a tendency to narrow thinking on the subject, and this is, after all, the food for medical research.

You can read the full comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293669/pdf/jrsocmed00107-0092a.pdf

 

Source: Wright B. Chronic fatigue syndrome and heterogeneity. J R Soc Med. 1992 Sep;85(9):588. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293669/

 

Outcome in the chronic fatigue syndrome

Comment in: Self help organization’s advice on myalgic encephalomyelitis. [BMJ. 1992]

Comment on: Follow up of patients presenting with fatigue to an infectious diseases clinic. [BMJ. 1992]

 

EDITOR,-Michael Sharpe and colleagues’ paper confirms what many clinicians have long suspected -namely, that the prognosis for those with a chronic fatigue syndrome who reach specialist care is poor.’ The paper also suggests that membership of a self help organisation is associated with a poor outcome. Although the authors emphasise that this association is not necessarily causal, I fear that the self help organisations may interpret this as another attack on their credibility, which will further sour relations between the organisations and the profession.

What are the possible explanations for these disturbing findings? Sharpe and colleagues suggest that patients’ beliefs are an important mediator of disability, a view I share.2 An article written by a sufferer illustrates how this might happen: “These living viruses are erratic and unpredictable. The prickly-edged ones pierce their way into the body cells. If disturbed by the patient’s activity they become as aggressive as a disturbed wasps’ nest, and can be felt giving needle-like jabs (or stimulating the nerves to do so).” It is easy to understand how such beliefs, regardless of their scientific accuracy, amplify disability.

You can read the full comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1882994/pdf/bmj00086-0047b.pdf

 

Source: Wessely S. Outcome in the chronic fatigue syndrome. BMJ. 1992 Aug 8;305(6849):365. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1882994/

 

Outcome in the chronic fatigue syndrome

Comment on: Follow up of patients presenting with fatigue to an infectious diseases clinic. [BMJ. 1992]

 

EDITOR,-Michael Sharpe and colleagues’ follow up study of 177 patients with chronic fatigue of uncertain origin raises several important unanswered questions, which require further investigation. Factors such as a belief that their illness followed an infection, intolerance to alcohol, and membership of a support group for patients with myalgic encephalomyelitis were all associated with an adverse prognosis. Could it be that the authors had identified patients belonging to a distinct postinfectious subgroup as many doctors maintain they do? Clearly, if this is the case future studies of this nature will have to include more objective analysis of persisting viral infection (for example, analysis of muscle biopsy specimens with the polymerase chain reaction rather than tests for VP1 antigen); immune function (for example, function of natural killer cells rather than white cell counts); and hypothalamic-pituitary-axis activity (for example, up regulation of serotonin- I receptors and basal cortisol concentrations) to see if there are characteristic abnormalities that distinguish the postinfectious subgroup.

The high incidence of intolerance to alcohol is noted as intriguing, but from personal experience, as well as from seeing many patients with a classic postinfectious fatigue syndrome, I regard this observation as an important diagnostic feature. In these patients even small amounts of alcohol cause a further deterioration in cognitive function, and I suggest that a physiological explanation may lie in the fact that alcohol increases the concentration of the neurotransmitter y-aminobutyric acid, which in turn reduces the availability of calcium ions and hence depresses brain function still further.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1883001/pdf/bmj00086-0047c.pdf

 

Source: Shepherd C. Outcome in the chronic fatigue syndrome. BMJ. 1992 Aug 8;305(6849):365. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1883001/

 

Outcome in the chronic fatigue syndrome

Comment on: Follow up of patients presenting with fatigue to an infectious diseases clinic. [BMJ. 1992]

 

EDITOR,-Michael Sharpe and colleagues report that most patients with the chronic fatigue syndrome rate contact with medical services as unhelpful or only slightly helpful. Many sufferers turn to alternative health care, again with varied success. Such dissatisfaction with medical care is well documented, and self help organisations flourish to provide the support, advice, and education that is not, or cannot be, provided by the medical profession; they potentially fulfil an important role.

The authors conclude that for patients with the chronic fatigue syndrome membership of a self help organisation is associated with a poorer outcome (although whether members were more functionally impaired at the outset is not known). Adopting coping strategies, particularly with regard to exercise and “stress,” and a belief in the persistence of a viral infection are also associated with continuing disability.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1883006/pdf/bmj00086-0047d.pdf

 

Source: Cope H, David AS. Outcome in the chronic fatigue syndrome. BMJ. 1992 Aug 8;305(6849):365. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1883006/