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Bansal: Investigating unexplained fatigue in general practice with a particular focus on CFS/ME

Discussion in 'Latest ME/CFS Research' started by mango, Jul 19, 2016.

  1. mango

    mango Senior Member

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    Investigating unexplained fatigue in general practice with a particular focus on CFS/ME

    Amolak S Bansal

    BMC Family Practice BMC series – open, inclusive and trusted 2016 17:81
    DOI: 10.1186/s12875-016-0493-0

    Received: 5 February 2016. Accepted: 13 July 2016. Published: 19 July 2016.

    Abstract
    Unexplained fatigue is not infrequent in the community. It presents a number of challenges to the primary care physician and particularly if the clinical examination and routine investigations are normal. However, while fatigue is a feature of many common illnesses, it is the main problem in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). This is a poorly understood condition that is accompanied by several additional symptoms which suggest a subtle multisystem dysfunction. Not infrequently it is complicated by sleep disturbance and alterations in attention, memory and mood.

    Specialised services for the diagnosis and management of CFS/ME are markedly deficient in the UK and indeed in virtually all countries around the world. However, unexplained fatigue and CFS/ME may be confidently diagnosed on the basis of specific clinical criteria combined with the normality of routine blood tests. The latter include those that assess inflammation, autoimmunity, endocrine dysfunction and gluten sensitivity. Early diagnosis and intervention in general practice will do much to reduce patient anxiety, encourage improvement and prevent expensive unnecessary investigations.

    There is presently an on-going debate as to the precise criteria that best confirms CFS/ME to the exclusion of other medical and psychiatric/psychological causes of chronic fatigue. There is also some disagreement as to best means of investigating and managing this very challenging condition. Uncertainty here can contribute to patient stress which in some individuals can perpetuate and aggravate symptoms. A simple clinical scoring system and a short list of routine investigations should help discriminate CFS/ME from other causes of continued fatigue.

    Keywords: Chronic fatigue syndrome Myalgic encephalomyelitis CFS/ME Medically unexplained fatigue Diagnostic criteria Scoring system Differential diagnosis

    http://bmcfampract.biomedcentral.com/articles/10.1186/s12875-016-0493-0
     
  2. duncan

    duncan Senior Member

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    What a crock.
     
  3. duncan

    duncan Senior Member

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    This line of thinking in particular blows me away.

    But there is no lack of gems in this abstract. I am puzzled how this kind of stuff gets published.
     
  4. John Mac

    John Mac Senior Member

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    Yes, give them a CFS diagnosis as quick as you can and get them out the door
     
  5. msf

    msf Senior Member

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    The ME establishment in the UK is totally compromised, with the possible exception of Julia Newton and those who have just joined the field.
     
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  6. TiredSam

    TiredSam The wise nematode hibernates

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    Every time the name Dr Bansal crops up on this forum I never know what to expect next, he's been spoken of very positively and very negatively at various times by various people. Can't say I'm very impressed with this:

    Also wasn't very impressed by this gem earlier on:

     
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  7. worldbackwards

    worldbackwards A unique snowflake

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    I think we're getting the idea now :grumpy:
     
  8. jodie100

    jodie100

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    I think this is actually a really good article if you read the whole thing thoroughly and read things in context. I assume it is aimed at GPs and is a good summary of the current state of affairs and how they can diagnose and help M.E. patients given the current limited knowledge of its causes. To me it seems to be advocating for M.E. patients and seeking to improve their treatment and is a step in the right direction. If all GPs had this much knowledge about M.E/CFS it would be an improvement ,so I find it a bit disheartening to see mostly criticisms of it.
     
  9. duncan

    duncan Senior Member

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    The very first word of the study is "Tiredness."

    For me, that's enough context.

    Unfortunately, there is plenty more where that came from.
     
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  10. Comet

    Comet I'm Not Imaginary

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    How about this means of investigation? Listen to patients. Believe what they are telling you. Investigate. Adjust as necessary.
     
  11. Kati

    Kati Patient in training

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    Socialized medicine is very reluctant to investigate issues. The book of medicine is already written, they say. Family drs do not have authority to perform many tests, and medical specialties have no room for a disesse such as ours.

    The medical profession is moving very slowly. Hopefully things will change soon.
     
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  12. Esther12

    Esther12 Senior Member

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    It's not critical enough of the rubbish research it cites.

    A lot of people here are not going to be cheering baby steps in the right direction when we're in such a dire position and it would be so easy to make huge strides.
     
  13. alex3619

    alex3619 Senior Member

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    On my reading the medical profession is being driven backwards, largely by forces that are outside the profession and they do not usually challenge. Scientific research still progresses, and we have good research happening, but any breakthrough in research only fixes the specific research issue, not the general problems. Those are largely medico-political, and indeed even cultural.

    This is not isolated to socialized medicine either, though arguably the problem is worse there. HMOs and insurance companies similarly limit tests and treatments.
     
    Last edited: Jul 19, 2016
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  14. Hutan

    Hutan Senior Member

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    Here's another one:

    As in, 'I confidently diagnose you with 'unexplained fatigue'. ? And the utility of that is what?
     
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  15. Hutan

    Hutan Senior Member

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    Ah, silly me. I should have read further:
    As in 'I confidently diagnose you with 'unexplained fatigue'. So now you can stop being anxious, get better and not waste any more of the resources of the health system'.
     
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  16. Kati

    Kati Patient in training

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    One more reason to get ME out of general practice and into a medical specialty (not psychiatry)
     
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  17. Valentijn

    Valentijn WE ARE KINA

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    He doesn't even know the main symptoms of the disease he's purporting to give an expert opinion about. PEM is "the predominant and most disabling symptom", not fatigue.

    And how exactly is CBT and GET expected to treat a disease involving those symptoms?

    Anyone who feels compelled to uncritically discuss neurasthenia as the precursor of ME is blatantly undermining ME as a biomedical diagnosis. There might be an excuse if the author is showing how neurasthenia was hijacked by psychobabblers, much as ME has been, but the word itself is now used to describe a fashionable psychosomatic disorder.

    Well, he got one thing right at least.

    table2.jpg
    Bansal considers a score of 8 to be diagnostic, so PEM is optional :meh: He says it's required in some form, but his description is broad and vague enough that pretty much any exercise intolerance can qualify. And extra points are available for alcohol intolerance, intolerance of meds, cold limbs, and frequent sighing.

    He talks about it not really being relevant to symptoms, but sure does spend a lot of time focusing on psychobabble. He's not conveying a good impression of the disease to anyone reading his paper.

    Pacing and GET are complete polar opposites. How could anyone put them on the same list of recommended treatments? Does he understand that the CBT he's promoting is based on convincing patients that they are not ill at all? Why a prominent mention of pharmaceuticals for mood disorders but not physical symptoms like pain or OI?

    No, it didn't confirm any such thing. In fact, the long-term follow-up study showed CBT and GET to be completely worthless.

    All of that said, this paper isn't completely bad. Some of it is even very good. But the author seems to have a complete inability to distinguish between quality and junk research, and it all seems to be accepted and presented as being equally valid.

    This often contrasts with Bansal's clinical observations, which generally seem consistent with what patients experience of ME. But those observations are vague and subjective, making them sound rather weak and unconvincing at points.

    His list of alternative diagnoses to rule out isn't bad, though I find his attitude to end wasting money on testing after that (unless otherwise indicated) to be rather distasteful. Just because other diseases have been ruled out, it doesn't mean that testing won't reveal problems which can be treated. He also speaks pretty favorably about OI testing, which is a minor miracle in the UK.

    Unfortunately, the positive points are often drowned out by the long discussions of the research claiming that we're all nuts, and generally not worth the expense of being tested. He seems to be going for a typical compromise position, based on the undeniable reality he sees in patients, but combined with an inability to question the psychobabble research.
     
    Last edited: Jul 20, 2016
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  18. Dx Revision Watch

    Dx Revision Watch Owner of Dx Revision Watch

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    https://www.epsom-sthelier.nhs.uk/chronic-fatigue-syndrome

    Chronic fatigue syndrome

    Our Chronic Fatigue Service (CFS), based at Sutton Hospital, with clinics at St Helier Hospital, provides management and support for people with CFS.

    The service was opened in early 2005 under the leadership of Dr Amolak Bansal, consultant immunologist at St Helier Hospital, as part of the Department of Health’s chronic fatigue clinical network collaborative to introduce services for individuals with chronic fatigue syndrome where none existed...


    Page includes summary of the clinic's Lifestyle management group programme and links for patient information leaflets, for example, leaflet (under "Re-evaluating thoughts"):

    EVALUATE YOUR UNHELPFUL THOUGHTS

    "...If you would [sic] further information on challenging unhelpful thoughts there is a helpful chapter in Overcoming Chronic Fatigue: A Self-help Guide Using Cognitive-Behavioural Techniques by Mary Burgess with Trudie Chalder (Chapter8: Overcoming unhelpful thinking patterns pp 86-127)."
     
    Last edited: Jul 20, 2016
  19. Snow Leopard

    Snow Leopard Hibernating

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  20. Marky90

    Marky90 Science breeds knowledge, opinion breeds ignorance

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    That`s exactly the problem.

    I remember when I was studying 1st year experimental psychology at bristol uni, from time to time - under huge time pressure, I had to write summaries about research I didn`t even remotely understand. I still got good grades, through extensive citing, and dubious conclusions.

    These people are doing exactly the same - but are paid for it.
    The art of fogwriting.
     
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