Tag: critique

Chronic fatigue syndrome/myalgic encephalitis

Comment in: Chronic fatigue syndrome/ME. [Br J Gen Pract. 2002]

Comment on: Doctors and social epidemics: the problem of persistent unexplained physical symptoms, including chronic fatigue. [Br J Gen Pract. 2002]

 

In their editorial (Journal, May 2002), Stanley et al argued that chronic fatigue should be categorised under ‘persistent unexplained physical symptoms’, and that these are often the result of the somatisation of ‘unhappiness’ and the misinterpretation of ‘normal functioning’. However, their analysis contained some notable flaws.

Firstly, there is more to chronic fatigue syndrome (CFS) than ‘tiredness and its synonyms’ and to ignore symptoms, such as vertigo, nausea, and photophobia, both misrepresents and trivialises this illness.

Secondly, the authors alluded to widespread somatisation, despite the lack of evidence that this is a major problem in relation to CFS. The suggestion that this is a homogeneous population of unhappy, prejudiced, attention-seekers is difficult to reconcile with evidence-based medicine, and the subtle accusations of mass exaggeration are stigmatising and unhelpful.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314419/pdf/12236282.pdf

 

Source: Goudsmit E. Chronic fatigue syndrome/myalgic encephalitis. Br J Gen Pract. 2002 Sep;52(482):763; author reply 763-4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314419/pdf/12236282.pdf (Full article)

 

Chronic fatigue syndrome/myalgic encephalitis

Comment on: Doctors and social epidemics: the problem of persistent unexplained physical symptoms, including chronic fatigue. [Br J Gen Pract. 2002]

 

The editorial in the May 2002 issue by Drs Stanley, Peters and Salmon1 questions the validity of the report to the Chief Medical Officer stating that chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) ‘is indeed a chronic illness meriting significant NHS resources, including the unreserved attention of the medical profession.’ They suggest that CFS/ME may be a ‘social epidemic’ where symptoms are generated by psychogenic mechanisms. They set high standards for discussions of these issues, advocating that information ‘must be interpreted within a rigorous scientific framework such as that afforded by the methods of qualitative research.’ Let us do just that. There have been repeated reports of objectively measurable physiological changes in CFS/ME.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314419/pdf/12236282.pdf

 

Source: Pall ML. Chronic fatigue syndrome/myalgic encephalitis. Br J Gen Pract. 2002 Sep;52(482):762; author reply 763-4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314419/pdf/12236282.pdf (Full article)

 

Chronic fatigue syndrome/myalgic encephalitis

Comment on: Doctors and social epidemics: the problem of persistent unexplained physical symptoms, including chronic fatigue. [Br J Gen Pract. 2002]

 

Readers of your editorial of May 2002 may easily gain the impression that the medical profession’s ‘established scientific methods’ have shown that CFS/ME is not a real illness and that people with CFS/ME are not really ill but are simply unhappy.

Such a perception of CFS/ME runs strongly counter to our experience at the registered charity, Westcare UK. Over the past 13 years we have been offering, with beneficial results, professional help to well over 700 patients with CFS/ME.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314419/pdf/12236282.pdf

 

Source: Sykes R. Chronic fatigue syndrome/myalgic encephalitis. Chronic fatigue syndrome/myalgic encephalitis. Br J Gen Pract. 2002 Sep;52(482):762-3; author reply 763-4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314419/pdf/12236282.pdf (Full article)

 

Editorial on CFS was biased, inaccurate, and misleading

EDITOR—As a member of the chief medical officer’s working group on chronic fatigue syndrome, I consider that Straus has failed to appreciate the difficulties of deciding what constitutes evidence in an illness as uncertain and heterogeneous as this.1 He also misunderstood, or took out of context, some of the key conclusions and recommendations in the chief medical officer’s report.

Although it was agreed that evidence should not just be limited to the results of randomised controlled trials, the findings of the York systematic review were frequently cited. It was therefore disingenuous of Straus to state that information from this review did not influence the report’s conclusions about a wide range of therapeutic interventions. It did.

Equally, it would have been a serious omission if the report had failed to refer to the feedback from patients contained in three large surveys on attitudes to management, as well as two events where patients and carers met with the working group. All three surveys concluded that graded exercise as is currently being done made more people worse than any other intervention. Pacing, however, was found to be beneficial by around 90% of respondents. By dismissing such views as anecdote, Straus fails to appreciate that the Department of Health is encouraging patients to enter into a therapeutic relationship with the medical profession in the management of chronic conditions such as this.2

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122848/

 

Source: Shepherd C. Editorial on CFS was biased, inaccurate, and misleading. BMJ. 2002 Apr 13;324(7342):914. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122848/ (Full article)

 

Chronic fatigue syndrome

Comment in: Chronic fatigue syndrome. [Br J Gen Pract. 2001]

Comment on: Frequency of attendance in general practice and symptoms before development of chronic fatigue syndrome: a case-control study. [Br J Gen Pract. 2001]

 

The study of Hamilton et al in the July issue of the BJGP, 1 claims that a higher consultation rate in people with chronic fatigue syndrome (CFS) before they develop the diagnosis supports the hypothesis that behavioural factors have a role in its aetiology. A similar case-control study of mothers and fathers of Down’s syndrome children showed that both mothers and fathers had significantly more recorded illnesses before the birth of the child and that the mothers had significantly more psychosis, neurosis or self-poisoning.2

The problem with such findings is deciding what they mean. No-one would suggest that Down’s syndrome is caused by ‘behavioural factors,’ so why should anyone believe that of CFS? There is no more evidence that increased frequency of attendance before diagnosis points to behavioural factors in CFS than that it points to non-dysjunction in the germ cells of mothers of Down’s syndrome children.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314117/pdf/11593850.pdf

 

Source: Murdoch JC. Chronic fatigue syndrome. Br J Gen Pract. 2001 Sep;51(470):758. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314117/pdf/11593850.pdf (Full comment)

 

Chronic fatigue in general practice

Comment on: Chronic fatigue in general practice: is counselling as good as cognitive behaviour therapy? A UK randomised trial. [Br J Gen Pract. 2001]

 

Ridsdale and colleagues are to be congratulated on performing a randomised controlled trial of different treatments for chronic fatigue. However, their data do not substantiate their conclusions.

The trial was set up to demonstrate that cognitive behavioural therapy was better than counselling for patients seen in general practice with fatigue symptoms. No difference in the main outcome measures was found between the intervention and control groups. This has been interpreted as showing that the two treatments are equivalent. The sample size required for, and analysis of, equivalence studies are different than those required for trials designed to show differences,2 not least the requirement that equivalence be defined before the trial starts. This trial was not designed to show equivalence. Thus, although the results for the main outcome measures are similar they should not be reported as being equivalent. Without a definition of equivalence, calculating the study’s power to show equivalence is not possible. Also, part of the conclusions depend on a sub-group analysis which, while acknowledged as being underpowered, is given more weight than is justified. If equivalence is defined as six points on the fatigue score then, in this subgroup, the trial only has a power of 36% to show equivalence based on a 95% confidence interval. With a more conservative definition of equivalence even the main study lacks power.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313987/pdf/11458490.pdf

 

Source: Underwood M, Eldridge S. Chronic fatigue in general practice. Br J Gen Pract. 2001 Apr;51(465):317-8. http://www.ncbi.nlm.nih.gov/pubmed/11458490

 

Cognitive behaviour therapy and chronic fatigue syndrome

Comment on: Chronic fatigue in general practice: is counselling as good as cognitive behaviour therapy? A UK randomised trial. [Br J Gen Pract. 2001]

 

Ridsdale and colleagues state that there is evidence that cognitive behaviour therapy (CBT) is effective for patients with chronic fatigue syndrome (CFS), but fail to point out that such evidence derives only from studies performed in the United Kingdom, where CFS is diagnosed on the basis of the Oxford criteria. There is no evidence that CBT is beneficial to patients fulfilling the Australian criteria for CFS or the American ones, namely, the original criteria of the Centers for Disease Control.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313986/pdf/11458489.pdf

 

Source: Baschetti R. Cognitive behaviour therapy and chronic fatigue syndrome. Br J Gen Pract. 2001 Apr;51(465):316-7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313986/ (Full comment)

 

Patient education to encourage graded exercise in chronic fatigue syndrome. Trial has too many shortcomings

Comment on: Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome. [BMJ. 2001]

 

Editor—Powell et al’s controlled trial of graded physical exercise in chronic fatigue syndrome has several shortcomings.1

Firstly, the only tool that was used to assess the level of physical activity was entirely subjective. This was a single item (the third item) of the 11 item standardised SF-36 health survey questionnaire. Use of this single item alone as a valid measure of physical fitness is hardly acceptable in the absence of objective data.

Secondly, in a randomised study one can only compare like with like. In this case, all patients in the intervention arms had a minimum of three telephone contacts during the first three months. Patients in the control group were abandoned to primary care after the randomisation. Why did the investigators not maintain the same number of telephone contacts with the control group? They could have discussed anything but chronic fatigue.

Thirdly, frequent early contacts with patients in the three intervention groups (and not the control group) might have confounded the outcome measures by positively influencing the results. This view is supported by the maximum difference emerging as early as three months among patients who had had the illness for an average of over four years, with little change thereafter. By speaking to the patients Powell et al might have provided them with a coping strategy that the control group could not access. Furthermore, did the authors ask the patients to keep an activity diary to record the intensity (mild/moderate) and duration (minutes/hours a day) of physical exercise so that they could note any difference across the intervention groups?

Because no objective measures of physical activity (for example, exercise endurance) were included before and after the interventions for assessing outcome in this study, the reported beneficial effects of graded physical exercise are based on weak evidence. Moreover, the authors did not use the current diagnostic criteria to select patients with chronic fatigue syndrome. Why are we reading this in the BMJ?

You can read the full comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1120585/

 

Source: Chaudhuri A. Patient education to encourage graded exercise in chronic fatigue syndrome. Trial has too many shortcomings. BMJ. 2001 Jun 23;322(7301):1545-6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1120585/ (Full comment)

 

On the epidemiology of ‘mysterious’ phenomena

Abstract:

In the field of epidemiology, research topics are favored or dismissed depending on whether respective variables under investigation are believed to exist according to current scientific theories. Unconventional independent variables or exposures, such as religiousness and spirituality, and controversial dependent variables or outcomes, such as chronic fatigue syndrome, may be considered unacceptable topics for researchers because they do not fit comfortably into the consensus clinical perspectives of mainstream medical scientists or physicians.

Disapproval of research in these and other taboo areas is generally masked by claims that such studies are “pseudoscientific,” despite hundreds or thousands of peer-reviewed publications on these topics. In reality, seemingly “mysterious” variables are equally as amenable to epidemiologic research as any other exposure or disease. Similarly, alternative therapies are able to be investigated using existing methods, despite claims to the contrary. Such research is vital for scientific understanding to be expanded into new areas of inquiry.

 

Source: Levin J, Steele L. On the epidemiology of ‘mysterious’ phenomena. Altern Ther Health Med. 2001 Jan;7(1):64-6. http://www.ncbi.nlm.nih.gov/pubmed/11191044

 

Diagnose and be damned. Corroboration is important when children’s illnesses are diagnosed

EDITOR—Marcovitch’s arguments about treatment of the chronic fatigue syndrome (myalgic encephalomyelitis) in children are illogical.1 He writes of the “hatchet job” performed by Panorama in the programme of 8 November and refers to the Washington Post’s policy that news requires corroboration.

One of the responses to his article, by Wessely [published here, p 1005], states, “contrary to the message of the programme, the management of chronic fatigue syndrome in children is not contentious.”2 In referring to a case reported by Panorama Marcovitch states that “parents’ views and those of the local medical team were in conflict.” Yet the programme made clear that the dispute was between the parents supported by their own medical advisers and the local medical team, so perhaps there is greater disagreement than has been asserted.

Marcovitch discussed at length Munchausen’s syndrome by proxy; Panorama labelled one of the cases of myalgic encephalitis as being a case of this syndrome. No one likes receiving emotional, intemperate outbursts, even from people who think they have been wrongly accused. But what is sauce for the goose is surely sauce for the gander. Even doctors sometimes make mistakes, yet Marcovitch disregards the possibility that parents, knowing themselves innocent, may feel themselves to have been receiving exactly the same type of vituperative attack that he objects to when doctors are on the receiving end. Such allegations turn on fact rather than clinical opinion so should be subject to Marcovitch’s own test of corroboration.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117876/

 

Source: Pheby D. Diagnose and be damned. Corroboration is important when children’s illnesses are diagnosed. BMJ. 2000 Apr 8;320(7240):1004. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117876/ (Full article)