The use of the Internet amongst gastroenterology out-patients.

De Lorenzo and colleagues' report a previously undefined relationship between chronic fatigue syndrome (CFS) and phosphate diabetes. They also report that mean serum phosphate concentration was found to be significantly lower in CFS patients than in control subjects. They explain their findings by the hypothesis that CFS patients have a metabolic defect that is secondary to their chronic underutilisation of skeletal muscle. Another hypothesis can, however, be proposed. Hypophosphataemia in sepsis has been recently reported to be associated with high levels of tumour necrosis factor-a and interleukin-6.' However, these inflammatory cytokines are also produced to excess in both CFS patients3 and hypocortisolaemic subjects.4 De Lorenzo and colleagues' findings,' therefore, may simply reflect the hypocortisolism of CFS patients,5 which is one of the 20 features that CFS shares with Addison's disease.5phate diabetes in patients with chronic fatigue Prevalence of hypo-phosphatemia in sepsis and infection: the role of cytokines. Altered cyto-kine release in peripheral blood mononuclear cell cultures from patients with the chronic fatigue syndrome. Chrousos GP. Acute glucocorticoid deficiency is associated with plasma elevations of interleukin-6: does the latter participate in the symptomatology of the steroid withdrawal syndrome and adrenal insufficiency? Y Clin Asymptomatic murmurs Sir, I read with interest the article entitled 'Asymptomatic murmurs' by Biggart and Coltart.' Although the patient was eventually diagnosed to have an unruptured aneurysm of the sinus of Valsalva, the murmur was due to the coexistent aortic stenosis. It was by chance that echocardiogram, which was performed for assessment of the systolic murmur and showed mild aortic stenosis, revealed a bizarre right atrial echo. The latter, in combination with a large calcified mass in the region of the right atrium, led to the clinical suspicion of a calcified aneurysm of the sinus of Valsalva, which was confirmed by ascending aortography. It should be emphasized that unruptured aneurysms of sinus of Valsalva are usually asymptomatic and do not produce any heart murmurs. As was cited as reference 4 in the article, my colleagues in China and 12 reported the value ofthree-dimensional trans-oesophageal echocardiography in making the diagnosis of an unruptured aneurysm of sinus of Valsalva and in distinguishing it from an atrial myxoma. The use of the Internet amongst gastroenterology outpatients Sir, The Internet is becoming a widely available source of knowledge and is being used to disseminate information to a large audience.' The rapid growth of the Internet has been associated with the development of …