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Diagnostic lab tests - ideal list for medical care guide

Discussion in 'Laboratory and Genetic Testing' started by Hutan, Jan 29, 2019.

  1. Hutan

    Hutan Moderator Staff Member

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    This is the existing advice to doctors for tests for the diagnosis of ME/CFS from a New Zealand health board:

    1. Laboratory tests should be limited and dependent on the history and examination.1 Only repeat bloods if there is a good clinical indication.

    Consider these blood tests

    · CBC, CRP, ferritin

    · Electrolytes, renal and liver function, calcium, magnesium, blood glucose

    · Thyroid function

    · Coeliac antibodies

    · Other tests only if clinically indicated:

    · If associated with a viral illness, consider Epstein-Barr virus, cytomegalovirus, HIV testing. Lyme disease does not exist in New Zealand and should not be routinely tested for.

    · Immunoglobulins, antinuclear antibodies, rheumatoid titres, creatinine kinase, and cortisol should not be routinely checked.​
    What do you think? Are there any important tests missing? What tests should be repeated annually?
     
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  2. Amw66

    Amw66 Senior Member (Voting Rights)

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    Vit D and active VitB12 ( might be via MMA) , urinalysis.
    Full thyroid not just TSH.

    Comparuson of tests is worth highlighting- things may be within " normal" ranges but move - you can pick up on glucose and thyroid changes, and liver function changes

    It would also be worth flagging up that there is some evidence of reduced blood flow and tests may therefore require interpretation with symptoms rather than ranges.
     
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  3. Hutan

    Hutan Moderator Staff Member

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    From:
    Initiating Care of a Patient With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), 2019, Lapp

    The Centers for Disease Control and Prevention has recommended (8):

    • Complete blood count (CBC).
    • Comprehensive Metabolic Panel (electrolytes, BUN, creatinine, glucose, calcium, phosphorus, total protein, albumin, globulin, alkaline phosphatase, SGOT/ALT, SGPT/AST).
    • C-reactive protein or Westergren sedimentation rate.
    • Thyroid function tests.
    • TSH is least important due to HPA Axis suppression in ME/CFS.
    • Free T4 and/or total T3.
    • Urinalysis.

    Additionally, obtain any other laboratory studies indicated by your history and exam, such as:
    • ANA, Rheumatoid Factor or anti-CCP antibodies.
    • Cranial MRI if Multiple Sclerosis or other neurological disorder suspected, although small T2 weighted high intensity white matter lesions are seen in about 80% of cases.
    • Overnight sleep study (primary sleep disorders such as apnea and periodic leg movement syndrome occur in up to 60% of patients).
    • Sjogren's antibodies [SSA (Ro)/SSB (La)] if dry eyes and mouth are present.
    • Lyme serology (ELISA) or Western Blot if patient has had tick exposure or comes from an endemic area (Northeast US, Wisconsin area, California, and others).
    • Hepatitis C serology if “at risk” or has had elevated liver function tests.
    • CPK if muscle tenderness is present and myositis is suspected.
    • Obtain consultation if a significant psychiatric condition is present or suspected.
     
  4. Hutan

    Hutan Moderator Staff Member

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    From the Scottish Good Practice Statement for ME-CFS 2010

    1. Relevant investigations should be performed to aid in the differential diagnosis of ME‐ CFS and to exclude other illnesses.
      All patients

      • Full blood count (FBC)
      • Urea, electrolytes and creatinine (U&Es)
      • Liver function tests, including albumin (LFTs)
      • Thyroid function tests (TFTs)
      • Glucose (random)
      • Erythrocyte Sedimentation Rate (ESR)
      • C‐reactive protein (CRP)
      • Calcium
      • Creatine kinase
      • Ferritin
      • Urinalysis

        When indicated by history or examination
      • Antimitochondrial antibodies (AMA) (if minor alterations in LFTs)
      • Antinuclear antibody test (ANA)
      • Cytomegalovirus (CMV)
      • Coeliac serology (if diarrhoea/altered bowel habit, weight loss or history of
        autoimmune disorders and in patients with a family history of coeliac disease)
      • Epstein‐Barr Virus (EBV)
      • Extractable Nuclear Antigens (ENA)
      • Human Immunodeficiency Virus (HIV)
      • Hepatitis B and C
      • Lyme serology
      • Serology for chronic bacterial infections
      • Toxoplasma
      • Electrocardiogram (ECG) (if any cardiological symptoms)
     
  5. Ravn

    Ravn Senior Member (Voting Rights)

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    That looks a bit thin, especially for an initial work-up when alternative diagnoses need to be excluded. Not surprised though, our Health Boards are all about saving money.

    Reminds me of an incident a few years ago. My doctor decided to test my Vit D levels because 1) at the time it was thought I had MS which has been linked to low Vit D and 2) I have a condition that means I don't tolerate sunlight. I had been supplementing at recommended rates but the doctor wanted to be sure it was enough. So there were clinical reasons for doing the test.

    The letter with my test report stated “result strongly suggests Vitamin D deficiency”.

    Then letter continued: “This is an expensive test. Many adult patients with no bone symptoms who may have low Vitamin D because of limited exposure to sun-light can be managed by taking Vitamin D without prior testing.”

    Now that sort of comment really encourages doctors to be thorough. Not!
     
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  6. Milo

    Milo Senior Member (Voting Rights)

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    One of our latest scientist to join this forum @Amy Proal has written about vitamin D


    19. Vitamin D is not a “miracle” and recent RCTs do not support supplementation:
    For a decade now, my team has published papers and book chapters that call for an end to high-dose vitamin D supplementation. Our research indicates that the low levels of vitamin D often identified in patients with chronic inflammatory disease may be a result, rather than a cause of the disease process (eg, the concept of “deficiency” is incorrect). These two large 2018 studies support an end to vitamin D supplementation:

    Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis

    Lead author: Alison Avenues, University of Aberdeen

    This large meta-analysis published in the Lancet found vitamin D supplementation does not prevent fractures/falls, or have clinically meaningful effects on bone mineral density.

    Paper highlight: “There is little justification to use vitamin D supplements to maintain or improve musculoskeletal health. This conclusion should be reflected in clinical guidelines”

    Vitamin D Supplements and Prevention of Cancer and Cardiovascular Disease

    First author: JoAnn Manson, Harvard University

    This nationwide, randomized, placebo-controlled trial found that supplementation with vitamin D did not result in a lower incidence of invasive cancer or cardiovascular events than placebo

    From this link: http://microbeminded.com/author/amyproal/

    I bet that is we ask her she would be more than happy to talk to us about Vitamin D, testing and supplementation. I am curious to hear more.
     
  7. Snowdrop

    Snowdrop Senior Member (Voting Rights)

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    I would like to hear more too. I don't get natural sunlight due to not going outside so I'd like to know what to make of supplementation needs for this reason and for those who have had melanoma who need to reduce sun exposure.
     
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  8. Milo

    Milo Senior Member (Voting Rights)

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  9. Hutan

    Hutan Moderator Staff Member

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    I'm thinking about whether a cranial MRI should be recommended as part of the diagnostic screening for ME/CFS. Current online clinical guidelines in New Zealand discourage much testing, some actually stating that unnecessary testing is harmful for patients.

    It seems to me that the symptoms of early MS and MECFS are very very similar. I read the lists of symptoms for early MS and I can tick nearly every box. How would a doctor rule out MS without an MRI?

    I understand MRIs are expensive, but someone who has suddenly lost the ability to earn a living deserves a decent diagnostic effort. Feeling uncertain about what could possibly be causing the wide ranging symptoms is difficult; reducing that uncertainty should be worth some medical effort.

    Personally, I would far rather have an MRI and be able to cross MS and some other brain problems off the list than have multiple sessions with a therapist talking about how I feel. It seems that many doctors offer counselling quite readily but are reluctant to order tests.
     
  10. Ravn

    Ravn Senior Member (Voting Rights)

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    You are correct, there is significant symptom overlap. I was initially misdiagnosed with MS (via MRI). I then had a long period of almost-remission and when I relapsed the only reason I got another MRI is that I already had a relapsing-remitting MS diagnosis and the doctor feared it may have moved into the secondary progressive phase. Even with that the referring doctor wasn't confident that I would be accepted for an MRI and quoted a very high rejection rate (I can't remember the figure now) for MRIs in general. The system seems to be GP refers to specialist, specialist applies for MRI, some higher authority approves or refuses application. So this stinginess with MRIs applies across the board, not just to ME. Not that that makes it any more reasonable.
     
  11. Hutan

    Hutan Moderator Staff Member

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    Super interesting @Ravn. I have lots of questions, all of them quite intrusive - please feel free not to answer any of them.

    So you had some lesions show up on your first MRI but none or no change on a subsequent one? There have been a few members say that they had lesions show up on an MRI done soon after onset but that subsequent MRIs showed nothing. Not many people actually manage to get an MRI soon after onset.

    So, it seems that you had a false positive. Would you have rather not had the first MRI?

    How can you be sure that you have ME/CFS rather than MS that hasn't progressed?

    And just as a side question, did the care you got after the MS diagnosis differ from what you got after being given the diagnosis of ME/CFS?
     
  12. arewenearlythereyet

    arewenearlythereyet Senior Member (Voting Rights)

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    I was lucky in this respect. Because my first significant symptom was numb hands and feet suddenly getting worse ..my GP did MRI (neck) and nerve conduction tests to rule out MS. I wonder whether this can be used to check for perfusion (is that the right term?) as well as part of the test?

    Symptom profile also heavily overlaps with vit b12/folate/iron anaemia so I think this should also be automatically tested to rule out mainly because it is so easy to treat. This was the last test they gave me which seems strange.
     
  13. roller*

    roller* Senior Member (Voting Rights)

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    the nanoneedle-signal is the same for MS and MECFS
    ... NO, its not, as hutan explained. i misread this, sorry.

    what exactly to ask for regarding a diagnostic MS-MRI ?

    Sagittal T1-weighted MRI depicts multiple hypointense lesions in the corpus callosum;
    this finding is characteristic of multiple sclerosis.

    Sagittal proton density–weighted MRI in a patient with multiple sclerosis demonstrates the characteristic corpus callosal and pericallosal white matter lesions.

    Coronal fluid-attenuated inversion recovery (FLAIR) MRI in a patient with multiple sclerosis demonstrates periventricular high–signal intensity lesions, which exhibit a typical distribution for multiple sclerosis. FLAIR MRI is a highly sensitive sequence for lesion detection, particularly supratentorially

    Axial proton density–weighted MRI demonstrates multiple lesions in a distribution characteristic of multiple sclerosis.

    Specifically, the periventricular lesions and the more peripheral white matter lesions near the gray matter–white matter junction are typical MRI findings in multiple sclerosis.

    Axial proton density–weighted MRI through the posterior fossa in a patient with multiple sclerosis demonstrates multiple bright foci in the brainstem and cerebellum.

    Proton density–weighted sequences are highly sensitive for the detection of plaques in multiple sclerosis, especially in the posterior fossa.

    Axial T1-weighted, gadolinium-enhanced MRI in a patient with multiple sclerosis depicts enhancement of a plaque in the right temporo-occipital lobe, signifying disease activity.
    Note the C-shaped, or arclike, enhancement, which is fairly characteristic of multiple sclerosis.

    Axial T1-weighted, gadolinium-enhanced MRI in a patient with multiple sclerosis depicts several enhancing lesions, at least 2 of which show characteristic C-shaped, or arclike, peripheral enhancement.

    Axial T1-weighted, gadolinium-enhanced MRI in a patient with multiple sclerosis demonstrates several intensely enhancing pericallosal white matter lesions compatible with active disease.

    Axial T2-weighted MRI in a patient with multiple sclerosis demonstrates numerous white matter plaques in a callosal and pericallosal white matter distribution

    Axial diffusion-weighted MRI in a patient with multiple sclerosis shows several hyperintense lesions, a feature of inflammatory disease activity.
     
    Last edited: May 16, 2019
  14. Hutan

    Hutan Moderator Staff Member

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    @roller*, no, the nano-needle hasn't been tested on people with MS yet. @Cort was just saying that, if the nano-needle's signal was the same for both MS and ME/CFS, it wouldn't be a problem, as everyone testing positive with the nano-needle could then have an MRI.
     
    Last edited: May 16, 2019
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  15. duncan

    duncan Senior Member (Voting Rights)

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    I want to say the MRIs aren't THAT expensive, or at least not like a PET scan. Maybe $1,500 US, whereas a PET could be $10,000? It's been a while since I priced them, and my memory isn't want it once was, but I think it's broadly like that (check anyway, as I may be way off).

    I think if there is a strong suspician of neurological involvement, that a battery of brain scans should be available - but of course that's not going to happen.

    I wanted a SPECT, doctor ordered one, hospital refused. This happened twice with two distinct doctors and two different hospitals. One doctor was a world-class ME/CFS expert, and this was his hospital, and the radiology dept basically laughed at me when I told them who was ordering the scan.

    Had a PET Scan for an Alzheimers study. They came back and said no plaques. I asked what else it showed and was told that is proprietary. So that was a dead end.

    But I did have four brain MRI's and two showed lesions, and three showed mild brain atrophy. All four were ignored, so there's that frustrating component.

    I didn't ignore them, though. They helped me with my own research. I subsequently found a case study of a woman who's clinical profile was almost a match for mine due to those MRIs.

    So I'm all for MRI testing.
     
  16. adambeyoncelowe

    adambeyoncelowe Senior Member (Voting Rights)

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    In the UK, a private MRI is about £200-250, so I can't imagine it's much more expensive on the NHS. I've seen US prices at 8-10 times that ($2000-2500), but that's probably the effect of private healthcare and competition in the market.
     
  17. Hutan

    Hutan Moderator Staff Member

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    This is an interesting article.
    http://www.msdiscovery.org/news/news_synthesis/322-more-meets-eye
    It covers the different types of MRIs used to identify MS - lesions can be black or white depending on the type of imaging. It also shows an alarming video of slices of the brain of a man with MS, who was clinically stable over a year, made using the 24 MRIs he had over that year. He had lesions coming and going incredibly quickly all over the place.

    Like everything it seems, the more you know, the less certain things are.
     
    Last edited: May 16, 2019
  18. roller*

    roller* Senior Member (Voting Rights)

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    Diagnosing MS (wiki pages)

     
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  19. duncan

    duncan Senior Member (Voting Rights)

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    NeuroLyme can present with brain lesions. The theory is they dissipate with proper abx treatment, but with inadequate treatment, they can appear and reappear - much like the way that MS sufferer had lesions coming and going.

    Then you have the whole new anti-MOG thing (used to fall under MS umbrella until they learned more) that also can provoke lesions, and neurologists throw steroids at those, and/or IVIG, and MAYBE they dissipate. That's a crap shoot, too.

    The thing is, I don't think they really know all that much. They DO know that lesions are abnormalities, so let's start with that at least. But because they are so reluctant to spend the money, they frequently need to have a high confidence in their suspicion of whatever disease might be in play before they can take a picture - to see if they have any clue of what it might really be that they have little insight on how to cure anyways.

    It's silly, medically and financially. From my looonnnggg-ago college Economics101 course, I think the imaging equipment is a sunk cost. Salaries are fairly fixed. So income from using the facilities should be better the more times the equipment is used. Encourage use by dropping prices. Make use routine, the machine pays for itself. The hospital or imaging center is happy, radiologists are happy, doctors are happy, patients get more data. If it's socialised medicine, in effect everything is a sunk cost, so again, promote usage.

    As patients with a contested disease that little is known about, data is our best friend. Doctors can throw their hands up in...whatever, and walk away to another patient maybe they can help. We, with MRI pictures and other results, can roll up our sleeves and maybe make our own progress, at least in terms of moving toward a correct diagnosis.
     
    Last edited: May 16, 2019
  20. roller*

    roller* Senior Member (Voting Rights)

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    its really gross, that there are measurable and mostly visible damages all over the body, and nobody can figure where they come from.

    its a closed system of 1.80 m x 60 cm or something like that.
    roughly 1 sqm to investigate.

    they are at it for a couple of 1,000 years.

    one could also consider this SQM to be the most important question of mankind, since its existence.
    has always been more pressing than moon-landings or anything else.

    ridiculous.
     

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