921
effect of the examination fee on patient attendance is known. If it proves to be an impediment to patient attendance, then we can only urge that the free dental examination be reintroduced. Department of Dental Surgery, Dental School, Dundee DD1 4HN, UK
G. R. OGDEN
J. G. COWPE D. M. CHISHOLM
1. Nally F Oral cancer. Br Dent J 1988; 153: 240. 2. Bowden J, Scully C Dentistry and total oral health. Br Med J 1989; 298: 186. 3. Stell PM, McCormick MS. Cancer of the head and neck: are we doing any better? Lancet 1985; ii: 1127. 4 Scully C, Malamos D, Levers BGH, Porter SR, Prime SS. Sources and patterns of referrals of oral cancer role of general practitioners. Br Med J 1986; 293: 599-601. 5. Guggenheimer J, Verbin R, Johnson J, Horkowitz C, Myers E. Factors delaying the diagnosis of oral and oropharyngeal carcinomas. Cancer 1989; 64: 932-35. 6. Scott J, Cheah SB. The prevalence of oral mucosal lesions in the elderly in a surgical biopsy population: a retrospective analysis of 4042 cases. Gerodontology 1989, 8: 73-78 7. Office of Population Censuses and Surveys. Adult dental health 1988, United Kingdom. Todd JE, Lader D, eds. London: HM Stationery Office, 1991. 8. Johnson NW. Oro-facial neoplasms: global epidemiology, risk factors and recommendations for research. London: Federation Dentaire International, 1990. 9. Mashberg A, Samit AM. Early detection, diagnosis and management of oral and oropharyngeal cancer. Cancer 1989; 39: 67-88.
Costing operations SIR,- The difference in pricing for the same operation between different hospitals, referred to by Mr Dean (March 23, p 721) and highlighted in the media, largely depends on whether or not hospitals used the naive guidelines produced by the Department of Health. These state that calculations should be based on the mean number of days’ stay for a particular procedure. Thus an inpatient sigmoidoscopy (rarely an isolated procedure) is costed at over £ 800 because a few elderly patients admitted with constipation had just a sigmoidoscopy and then remained in hospital for many days while social problems were sorted out. Some hospitals’ finance directors felt bound to obey the guidelines to the letter however stupid the outcome: others took a more pragmatic and reasonable approach. The quoted costs, therefore, bear little relation to the actual costs or to the relative efficiencies of different hospitals. This is just another example of how unthought out policies and guidelines are being rushed through and being misinterpreted by the press. Royal Hallamshire Hospital, Sheffield S10 2JF, UK
W. E. G. THOMAS B. ROSS
Chair of tropical surgery SIR,-Mr Loefler (Feb 2, p 307) and Craven1 are justified in their claim that a chair of tropical surgery in Europe would be an "armchair". Nonetheless, we need, as Holcombe2 and you in your Dec 1 editorial suggest, academic posts in tropical surgery. But let them be established in tropical locations, and let them be funded by, and thus partly responsible to, European institutions. At present, support for academic surgeons in the third world is largely informal, consisting of laboratory and statistical services, exchange of trainees, and donations of second-hand but serviceable equipment. Without such support many of us would be unable to function. Tropical institutes, universities, and royal colleges could provide stronger incentives for academic surgery in the tropics by establishing chairs of surgery occupied by professors who practice in the developing world but who have access to laboratories, training, and research programmes, some of which would be based at home and others on location. This would advance in-country teaching, training, and research. It may be advantageous to encourage third-world research institutes and universities to compete for such externally funded chairs, which would provide staff and resources but be subject to regular review on the basis of academic record. The surgical colleges could provide further momentum by establishing a specialty fellowship appropriate for the third world.3 Such an examination would test breadth of knowledge across a wide range of subjects as well as depth of knowledge in a subspecialty. For example, a general surgeon in Zambia must be able to manage orthopaedic and gynaecological emergencies even if his special
interest is gastroenterology.’ Although the curriculum would vary from region to region, a specialty fellowship would enable tropical surgeons and their western colleagues to cooperate in the development of surgery in the tropics. Department of Surgery, University Teaching Hospital,
D. A. K. WAITERS
Lusaka, Zambia
1. Craven JL. A chair of tropical surgery. Br J Surg 1990; 77: 954. 2. Holcombe C. The need for a chair of tropical surgery. Br J Surg 1990; 77: 3-4. 3. Smith AN. New fellowships for old. Surgery (Internat ed) 1990; 8: i. 4. Watters DAK, Bayley AC. Training doctors and surgeons to meet the surgical needs of Africa. Br MedJ 1987; 295: 761-63.
Referral letters and case-notes of the sheriff in a Scottish fatal accident that "there is little point in a GP writing an inquiry (March 9, p 605) admission letter if it is not to be read by the person who takes charge of the case" is well taken. I have long been worried that in my hospital the GP’s letter is usually stuffed into the back pocket of the casenotes where it is rapidly submerged by the many irrelevant pieces of paper that we are constantly exhorted to keep for medicolegal reasons. My simple solution is to instruct the house-physicians to staple the referral letter to the first page of their clerking so that it is easily available for consultation or audit. This raises the more general difficulty of the ever increasing obesity of casenotes, especially of inpatients and those with chronic diseases. It is all very well for the Department of Health and its legal advisers to say that every piece of paper must be kept for eight years but I can foresee the situation where a patient will sue because the result of an important test was concealed in the jumble of temperature charts, fluid balance charts, and other ephemeral pieces of paper that pass for their notes. Perhaps when patients are allowed access to their records, they will, especially if they have no cause for legal action, demand that half the pieces of paper be deposited where they really belong, in the wastepaper basket.
SIR,- The
comments
University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH, UK
R. B. TATTERSALL
Calcipotriol and betamethasone valerate for psoriasis SIR,-We do not agree with Dr Kragballe and colleagues’ (Jan 26, p 193) statement that "calcipotriol holds great promise as an
antipsoriatic agent", on the basis of their report. Our disagreement stems not from a disbelief that calcitriol (or its analogues) has therapeutic activity in psoriasis, but from their enthusiasm for this treatment.
Our experience has been with calcitriol (1,25-dihydroxyvitamin D3) in a similar right/left double-blind design in patients with stable
plaque-type psoriasis, although we treated single plaques with one of three different concentrations and used a vehicle control at a similar contralateral site for 6 weeks. Improvements in erythema, scaling, induration, and overall severity were noted in both "active" and vehicle-treated plaques according to visual analogue scales (VAS), although the improvement was greater with calcitriol
(table). MEAN
(SD) VAS SCORES AFTER
Scores out of 100
post treatment
are
shown. *3
/1g/g n=4,
7
6 WEEKS’ TREATMENT
/1g/g n=5,15 /1g/g n=3. tPre and
922
Kragballe et al used betamethasone-17-valerate 0-1% (’Betnovate’) as the drug of comparison, and we believe that this provides a major difficulty in interpretation of their data. In our view, betnovate is by no means the best treatment for psoriasis. Several workers have shown that this topical corticosteroid, among others, does not fare well in comparisons with, for example, dithranol,l and that it is associated with earlier relapse than are other drugs. In addition, when corticosteroids are used to suppress psoriasis there is a real danger of pituitary adrenal suppression,2,3 skin thinning,4 and masked ringworm infection,s as well as the possibility of provoking the more serious condition of pustular psoriaiS.6 It is true that betamethasone valerate is widely used, but that is not a reason to compare its effect with other drugs. It might have been appropriate to compare calcipotriol with an identical but unmedicated vehicle control. Without this type of control it is difficult to know how much therapeutic activity is attributable to the drug and how much to the vehicle. Kragballe et al might have done better to use a preparation of dithranol, even though it would have made the double-blind design very difficult. Dithranol is acknowledged to be the most effective topical agent for psoriasis, and we would have obtained more useful information about the activity of the vitamin D3 analogue by comparison with this agent. Notwithstanding our minor criticisms of the trial design it is clear that topical vitamin D3 and its analogues have therapeutic activity, though the mechanism of action is puzzling. In our study, we did biopsies after treatment but showed only that the improvement in histological features and proliferative profile accorded with the clinical status; we cannot say from this finding if the agent has an antiproliferative effect. We hope that the arrival of a new class of topical agents for psoriasis that have a moderate suppressive activity will not inhibit more fundamental research to develop more effective remedies for this troublesome disease. Department of Dermatology, University of Wales College of Medicine,
C. C. LONG R. MARKS
Cardiff CF4 4XN, UK
1. Horwitz SN, Johnson RA, Sefton J, Frost P. Addition of a topically applied corticosteroid to a modified Goeckerman regimen for treatment for psoriasis: effect on duration of remission. J Am Acad Dermatol 1985; 13: 784-91. 2. Allenby CF, Main RA, Marsden RA, Sparkes CGG. Effect of adrenal function of topically applied clobetasol propionate (Dermovate). Br Med J1975; i: 619-21. 3. Staughton RCD, August PJ. Cushing’s syndrome and pituitary adrenal suppression due to clobetasol propionate. Br Med J 1986; ii: 419-21. 4. Dykes PJ, Marks R. An appraisal of the methods used in the assessment of atrophy from topical corticosteroids. Br J Dermatol 1979; 101: 599-606 5. Ive AF, Marks R. Tinea incognito. Br Med J 1969; iii: 149-52. 6. Baker H. Generalised pustular psoriasis. In: Roenigk HH Jr, Maibach HI, eds. Psoriasis. New York: Marcel Dekker, 15-33.
Maternal
alpha-fetoprotein congenital hypothyroidism serum
in
SIR,-Dr Ben-Neriah and colleagues (Feb 16, p 437) report two
pregnancies
with increased maternal
serum
alpha-fetoprotein
(MSAFP) concentrations (5-3 and 7-0 multiples of the median [MoM], respectively) at 17 weeks’ gestation, in which primary congenital hypothyroidism was subsequently diagnosed after birth. Based on these two cases, Ben-Neriah et al suggest an association between increased second trimester MSAFP values and congenital hypothyroidism and recommend thyroid stimulating hormone (TSH) measurements in amniotic fluid, followed by prenatal thyroxine therapy, when indicated. In 1972, one of our group identified a hypothyroid newborn baby with an increased serum AFP value.1 This finding, together with a 2 more comprehensive study on hypothyroid newborn children,2 prompted us to examine MSAFP concentrations from pregnancies where the infant was subsequently identified as having congenital hypothyroidism. Between January, 1980, and February, 1987, 31 cases of congenital hypothyroidism were identified in Maine, and 13 of these pregnancies had an MSAFP measurement at 15-20 weeks’ gestation. The median MSAFP value for the 13 pregnancies was 0-9 MoM (range 0-5-2-9 MoM) and only one of the 13 measurements was higher than the laboratory’s cut-off of 20 MoM. Our data
suggest that it is premature to recommend TSH measurements in amniotic fluid samples obtained from pregnancies with increased MSAFP values. JAMES E. HADDOW GEORGE J. KNIGHT Foundation for Blood Research, GLENN E. PALOMAKI Scarborough, Maine 04074, USA Moses H Cone Memorial Hospital, Greensboro, North Carolina
A. MYRON JOHNSON
serum level of &agr;1-fetoprotein in an infant with iatrogenic hypothyroidism. Clin Res 1972; 20: 56. 2. Larrson A, Hagenfeldt L, Blom L, Mortensson W. Serum alpha-fetoprotein: a biochemical indicator of prenatal hypothyroidism. Acta Paediatr Scand 1983; 72:
1.
Johnson AM, Salter KE High
481-84.
SIR,-Dr Ben-Neriah and his colleagues report very high maternal serum a-fetoprotein (MSAFP) concentrations in two women who were subsequently delivered of infants with congenital hypothyroidism. The values were 5-3 and 7-0 multiples of the normal median (MoM) at 17 weeks’ gestation. Ben-Neriah et al conclude that amniotic fluid thyroid stimulating hormone (TSH) should be measured in unexplained cases of raised MSAFP so that
begin antenatally. investigated the possible correlation between MSAFP and congenital hypothyroidism, using information from women and newborn babies having routine screening tests at John Radcliffe Hospital, Oxford, in 1979-89. We regarded a pregnancy as affected if the baby had a raised TSH on the routine dried blood spot, confirmed by TSH and either thyroxine or free thyroxine measurement in a subsequent serum sample and by physical examination. 21 singleton and 1 twin affected pregnancies were identified in which MSAFP had been tested. None of the singletons had raised MSAFP values (range 0-59-1 ’54 MoM, median 1-06). In treatment can
We
the twin pregnancy MSAFP concentration was 2-69 MoM but values in normal twins are roughly double those in singletons. Our results indicate that pregnancies affected by neonatal hypothyroidism have normal MSAFP concentrations. Our experience provides no reason to investigate cases of raised MSAFP for the possibility of this disease. Department of Environmental and Preventive Medicine, Medical College of St Bartholomew’s London EC1M 6BQ, UK
Hospital,
Nuffield Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford
Chronic
HOWARD CUCKLE NORA JONES JONATHAN KAY SUSAN STANDING
fatigue syndrome and depression
SIR,—While it is appropriate to assess the possibility of a relation between depressive disorders and chronic fatigue syndrome (CFS), Professor Kendell (Jan 19, p 160) ignores key epidemiological, psychiatric, and immunological findings. Our epidemiological study in an Australian community1 revealed that carefully defined CFS is present in at least 37 persons per 100 000, has a female to male sex ratio of 1-3/1, and occurs in children (8 of 42 cases identified were under 15). These demographic characteristics of CFS in the community do not resemble those of depression. Contrary to Kendell’s notion of a "glamorous disorder", cases of CFS in our survey came from all social classes, and the illness was associated with considerable personal losses and cost to the community. Kendell seeks to draw together similarities between CFS and depression but ignores important differences. Patients with typical primary depression are characterised by clinical features, such as anhedonia, weight loss, suicidal ideation, psychomotor retardation or agitation, and anxiety, that are notably absent in CFS.2,3 Furthermore, the severity of depression in patients with CFS is not comparable with that seen in non-melancholic depression, and the patients with CFS report lower amounts of neuroticism.3 4 Nor do they exhibit abnormal dexamethasone suppression3 or the shortened latency to rapid-eye-movement sleep5 found m depression. The rate of premorbid depressive disorders does not seem to be increased.4 Patients with CFS lack many essential
effect of the examination fee on patient attendance is known. If it proves to be an impediment to patient attendance, then we can only urge that the free dental examination be reintroduced. Department of Dental Surgery, Dental School, Dundee DD1 4HN, UK
G. R. OGDEN
J. G. COWPE D. M. CHISHOLM
1. Nally F Oral cancer. Br Dent J 1988; 153: 240. 2. Bowden J, Scully C Dentistry and total oral health. Br Med J 1989; 298: 186. 3. Stell PM, McCormick MS. Cancer of the head and neck: are we doing any better? Lancet 1985; ii: 1127. 4 Scully C, Malamos D, Levers BGH, Porter SR, Prime SS. Sources and patterns of referrals of oral cancer role of general practitioners. Br Med J 1986; 293: 599-601. 5. Guggenheimer J, Verbin R, Johnson J, Horkowitz C, Myers E. Factors delaying the diagnosis of oral and oropharyngeal carcinomas. Cancer 1989; 64: 932-35. 6. Scott J, Cheah SB. The prevalence of oral mucosal lesions in the elderly in a surgical biopsy population: a retrospective analysis of 4042 cases. Gerodontology 1989, 8: 73-78 7. Office of Population Censuses and Surveys. Adult dental health 1988, United Kingdom. Todd JE, Lader D, eds. London: HM Stationery Office, 1991. 8. Johnson NW. Oro-facial neoplasms: global epidemiology, risk factors and recommendations for research. London: Federation Dentaire International, 1990. 9. Mashberg A, Samit AM. Early detection, diagnosis and management of oral and oropharyngeal cancer. Cancer 1989; 39: 67-88.
Costing operations SIR,- The difference in pricing for the same operation between different hospitals, referred to by Mr Dean (March 23, p 721) and highlighted in the media, largely depends on whether or not hospitals used the naive guidelines produced by the Department of Health. These state that calculations should be based on the mean number of days’ stay for a particular procedure. Thus an inpatient sigmoidoscopy (rarely an isolated procedure) is costed at over £ 800 because a few elderly patients admitted with constipation had just a sigmoidoscopy and then remained in hospital for many days while social problems were sorted out. Some hospitals’ finance directors felt bound to obey the guidelines to the letter however stupid the outcome: others took a more pragmatic and reasonable approach. The quoted costs, therefore, bear little relation to the actual costs or to the relative efficiencies of different hospitals. This is just another example of how unthought out policies and guidelines are being rushed through and being misinterpreted by the press. Royal Hallamshire Hospital, Sheffield S10 2JF, UK
W. E. G. THOMAS B. ROSS
Chair of tropical surgery SIR,-Mr Loefler (Feb 2, p 307) and Craven1 are justified in their claim that a chair of tropical surgery in Europe would be an "armchair". Nonetheless, we need, as Holcombe2 and you in your Dec 1 editorial suggest, academic posts in tropical surgery. But let them be established in tropical locations, and let them be funded by, and thus partly responsible to, European institutions. At present, support for academic surgeons in the third world is largely informal, consisting of laboratory and statistical services, exchange of trainees, and donations of second-hand but serviceable equipment. Without such support many of us would be unable to function. Tropical institutes, universities, and royal colleges could provide stronger incentives for academic surgery in the tropics by establishing chairs of surgery occupied by professors who practice in the developing world but who have access to laboratories, training, and research programmes, some of which would be based at home and others on location. This would advance in-country teaching, training, and research. It may be advantageous to encourage third-world research institutes and universities to compete for such externally funded chairs, which would provide staff and resources but be subject to regular review on the basis of academic record. The surgical colleges could provide further momentum by establishing a specialty fellowship appropriate for the third world.3 Such an examination would test breadth of knowledge across a wide range of subjects as well as depth of knowledge in a subspecialty. For example, a general surgeon in Zambia must be able to manage orthopaedic and gynaecological emergencies even if his special
interest is gastroenterology.’ Although the curriculum would vary from region to region, a specialty fellowship would enable tropical surgeons and their western colleagues to cooperate in the development of surgery in the tropics. Department of Surgery, University Teaching Hospital,
D. A. K. WAITERS
Lusaka, Zambia
1. Craven JL. A chair of tropical surgery. Br J Surg 1990; 77: 954. 2. Holcombe C. The need for a chair of tropical surgery. Br J Surg 1990; 77: 3-4. 3. Smith AN. New fellowships for old. Surgery (Internat ed) 1990; 8: i. 4. Watters DAK, Bayley AC. Training doctors and surgeons to meet the surgical needs of Africa. Br MedJ 1987; 295: 761-63.
Referral letters and case-notes of the sheriff in a Scottish fatal accident that "there is little point in a GP writing an inquiry (March 9, p 605) admission letter if it is not to be read by the person who takes charge of the case" is well taken. I have long been worried that in my hospital the GP’s letter is usually stuffed into the back pocket of the casenotes where it is rapidly submerged by the many irrelevant pieces of paper that we are constantly exhorted to keep for medicolegal reasons. My simple solution is to instruct the house-physicians to staple the referral letter to the first page of their clerking so that it is easily available for consultation or audit. This raises the more general difficulty of the ever increasing obesity of casenotes, especially of inpatients and those with chronic diseases. It is all very well for the Department of Health and its legal advisers to say that every piece of paper must be kept for eight years but I can foresee the situation where a patient will sue because the result of an important test was concealed in the jumble of temperature charts, fluid balance charts, and other ephemeral pieces of paper that pass for their notes. Perhaps when patients are allowed access to their records, they will, especially if they have no cause for legal action, demand that half the pieces of paper be deposited where they really belong, in the wastepaper basket.
SIR,- The
comments
University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH, UK
R. B. TATTERSALL
Calcipotriol and betamethasone valerate for psoriasis SIR,-We do not agree with Dr Kragballe and colleagues’ (Jan 26, p 193) statement that "calcipotriol holds great promise as an
antipsoriatic agent", on the basis of their report. Our disagreement stems not from a disbelief that calcitriol (or its analogues) has therapeutic activity in psoriasis, but from their enthusiasm for this treatment.
Our experience has been with calcitriol (1,25-dihydroxyvitamin D3) in a similar right/left double-blind design in patients with stable
plaque-type psoriasis, although we treated single plaques with one of three different concentrations and used a vehicle control at a similar contralateral site for 6 weeks. Improvements in erythema, scaling, induration, and overall severity were noted in both "active" and vehicle-treated plaques according to visual analogue scales (VAS), although the improvement was greater with calcitriol
(table). MEAN
(SD) VAS SCORES AFTER
Scores out of 100
post treatment
are
shown. *3
/1g/g n=4,
7
6 WEEKS’ TREATMENT
/1g/g n=5,15 /1g/g n=3. tPre and
922
Kragballe et al used betamethasone-17-valerate 0-1% (’Betnovate’) as the drug of comparison, and we believe that this provides a major difficulty in interpretation of their data. In our view, betnovate is by no means the best treatment for psoriasis. Several workers have shown that this topical corticosteroid, among others, does not fare well in comparisons with, for example, dithranol,l and that it is associated with earlier relapse than are other drugs. In addition, when corticosteroids are used to suppress psoriasis there is a real danger of pituitary adrenal suppression,2,3 skin thinning,4 and masked ringworm infection,s as well as the possibility of provoking the more serious condition of pustular psoriaiS.6 It is true that betamethasone valerate is widely used, but that is not a reason to compare its effect with other drugs. It might have been appropriate to compare calcipotriol with an identical but unmedicated vehicle control. Without this type of control it is difficult to know how much therapeutic activity is attributable to the drug and how much to the vehicle. Kragballe et al might have done better to use a preparation of dithranol, even though it would have made the double-blind design very difficult. Dithranol is acknowledged to be the most effective topical agent for psoriasis, and we would have obtained more useful information about the activity of the vitamin D3 analogue by comparison with this agent. Notwithstanding our minor criticisms of the trial design it is clear that topical vitamin D3 and its analogues have therapeutic activity, though the mechanism of action is puzzling. In our study, we did biopsies after treatment but showed only that the improvement in histological features and proliferative profile accorded with the clinical status; we cannot say from this finding if the agent has an antiproliferative effect. We hope that the arrival of a new class of topical agents for psoriasis that have a moderate suppressive activity will not inhibit more fundamental research to develop more effective remedies for this troublesome disease. Department of Dermatology, University of Wales College of Medicine,
C. C. LONG R. MARKS
Cardiff CF4 4XN, UK
1. Horwitz SN, Johnson RA, Sefton J, Frost P. Addition of a topically applied corticosteroid to a modified Goeckerman regimen for treatment for psoriasis: effect on duration of remission. J Am Acad Dermatol 1985; 13: 784-91. 2. Allenby CF, Main RA, Marsden RA, Sparkes CGG. Effect of adrenal function of topically applied clobetasol propionate (Dermovate). Br Med J1975; i: 619-21. 3. Staughton RCD, August PJ. Cushing’s syndrome and pituitary adrenal suppression due to clobetasol propionate. Br Med J 1986; ii: 419-21. 4. Dykes PJ, Marks R. An appraisal of the methods used in the assessment of atrophy from topical corticosteroids. Br J Dermatol 1979; 101: 599-606 5. Ive AF, Marks R. Tinea incognito. Br Med J 1969; iii: 149-52. 6. Baker H. Generalised pustular psoriasis. In: Roenigk HH Jr, Maibach HI, eds. Psoriasis. New York: Marcel Dekker, 15-33.
Maternal
alpha-fetoprotein congenital hypothyroidism serum
in
SIR,-Dr Ben-Neriah and colleagues (Feb 16, p 437) report two
pregnancies
with increased maternal
serum
alpha-fetoprotein
(MSAFP) concentrations (5-3 and 7-0 multiples of the median [MoM], respectively) at 17 weeks’ gestation, in which primary congenital hypothyroidism was subsequently diagnosed after birth. Based on these two cases, Ben-Neriah et al suggest an association between increased second trimester MSAFP values and congenital hypothyroidism and recommend thyroid stimulating hormone (TSH) measurements in amniotic fluid, followed by prenatal thyroxine therapy, when indicated. In 1972, one of our group identified a hypothyroid newborn baby with an increased serum AFP value.1 This finding, together with a 2 more comprehensive study on hypothyroid newborn children,2 prompted us to examine MSAFP concentrations from pregnancies where the infant was subsequently identified as having congenital hypothyroidism. Between January, 1980, and February, 1987, 31 cases of congenital hypothyroidism were identified in Maine, and 13 of these pregnancies had an MSAFP measurement at 15-20 weeks’ gestation. The median MSAFP value for the 13 pregnancies was 0-9 MoM (range 0-5-2-9 MoM) and only one of the 13 measurements was higher than the laboratory’s cut-off of 20 MoM. Our data
suggest that it is premature to recommend TSH measurements in amniotic fluid samples obtained from pregnancies with increased MSAFP values. JAMES E. HADDOW GEORGE J. KNIGHT Foundation for Blood Research, GLENN E. PALOMAKI Scarborough, Maine 04074, USA Moses H Cone Memorial Hospital, Greensboro, North Carolina
A. MYRON JOHNSON
serum level of &agr;1-fetoprotein in an infant with iatrogenic hypothyroidism. Clin Res 1972; 20: 56. 2. Larrson A, Hagenfeldt L, Blom L, Mortensson W. Serum alpha-fetoprotein: a biochemical indicator of prenatal hypothyroidism. Acta Paediatr Scand 1983; 72:
1.
Johnson AM, Salter KE High
481-84.
SIR,-Dr Ben-Neriah and his colleagues report very high maternal serum a-fetoprotein (MSAFP) concentrations in two women who were subsequently delivered of infants with congenital hypothyroidism. The values were 5-3 and 7-0 multiples of the normal median (MoM) at 17 weeks’ gestation. Ben-Neriah et al conclude that amniotic fluid thyroid stimulating hormone (TSH) should be measured in unexplained cases of raised MSAFP so that
begin antenatally. investigated the possible correlation between MSAFP and congenital hypothyroidism, using information from women and newborn babies having routine screening tests at John Radcliffe Hospital, Oxford, in 1979-89. We regarded a pregnancy as affected if the baby had a raised TSH on the routine dried blood spot, confirmed by TSH and either thyroxine or free thyroxine measurement in a subsequent serum sample and by physical examination. 21 singleton and 1 twin affected pregnancies were identified in which MSAFP had been tested. None of the singletons had raised MSAFP values (range 0-59-1 ’54 MoM, median 1-06). In treatment can
We
the twin pregnancy MSAFP concentration was 2-69 MoM but values in normal twins are roughly double those in singletons. Our results indicate that pregnancies affected by neonatal hypothyroidism have normal MSAFP concentrations. Our experience provides no reason to investigate cases of raised MSAFP for the possibility of this disease. Department of Environmental and Preventive Medicine, Medical College of St Bartholomew’s London EC1M 6BQ, UK
Hospital,
Nuffield Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford
Chronic
HOWARD CUCKLE NORA JONES JONATHAN KAY SUSAN STANDING
fatigue syndrome and depression
SIR,—While it is appropriate to assess the possibility of a relation between depressive disorders and chronic fatigue syndrome (CFS), Professor Kendell (Jan 19, p 160) ignores key epidemiological, psychiatric, and immunological findings. Our epidemiological study in an Australian community1 revealed that carefully defined CFS is present in at least 37 persons per 100 000, has a female to male sex ratio of 1-3/1, and occurs in children (8 of 42 cases identified were under 15). These demographic characteristics of CFS in the community do not resemble those of depression. Contrary to Kendell’s notion of a "glamorous disorder", cases of CFS in our survey came from all social classes, and the illness was associated with considerable personal losses and cost to the community. Kendell seeks to draw together similarities between CFS and depression but ignores important differences. Patients with typical primary depression are characterised by clinical features, such as anhedonia, weight loss, suicidal ideation, psychomotor retardation or agitation, and anxiety, that are notably absent in CFS.2,3 Furthermore, the severity of depression in patients with CFS is not comparable with that seen in non-melancholic depression, and the patients with CFS report lower amounts of neuroticism.3 4 Nor do they exhibit abnormal dexamethasone suppression3 or the shortened latency to rapid-eye-movement sleep5 found m depression. The rate of premorbid depressive disorders does not seem to be increased.4 Patients with CFS lack many essential
