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plain of severe fatigue; in the last of these, fatigue may be the initial symptom Metabolic and endocrine diseases of various types may cause inordinate degrees of lassitude and fatigue Sometimes there is, in addition, a true muscular weakness In Addison and Simmonds diseases, fatigue may dominate the clinical picture Aldosterone de ciency is another established cause of chronic fatigue In persons with hypothyroidism with or without frank myxedema, lassitude and fatigue are frequent complaints, as are muscle aches and joint pains Fatigue may also be present in patients with hyperthyroidism, but it is usually less troublesome than nervousness Uncontrolled diabetes mellitus is accompanied by excessive fatigability, as are hyperparathyroidism, hypogonadism, and Cushing disease Reduced cardiac output and diminished pulmonary reserve are important causes of breathlessness and fatigue, which are brought out by mild exertion.

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Congenital Muscular Dystrophy (Fukuyama, Walker-Warburg, Merosin De cient, Rigid Spine, and Other Types) (See Table 50-4)

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Anemia, when severe, is another cause, probably predicated on a similar inadequacy of oxygen supply to tissues Mild grades of anemia are usually asymptomatic, and lassitude is far too often ascribed to it An occult malignant tumor eg, pancreatic carcinoma may announce itself by inordinate fatigue In patients with metastatic carcinoma, leukemia, or multiple myeloma, fatigue is a prominent symptom Uremia is accompanied by fatigue; the associated anemia may play a role Any type of nutritional de ciency may, when severe, cause lassitude; in its early stages, this may be the chief complaint Weight loss and a history of alcoholism and dietary inadequacy provide the clues to the nature of the illness For several weeks or months following myocardial infarction, some patients complain of fatigue out of all proportion to effort In many of these patients, there is accompanying anxiety or depression.

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Much more dif cult to understand is the complaint of fatigue that sometimes precedes myocardial infarction Pregnancy causes fatigue, which may be profound in the later months To some extent the underlying causes, including the work of carrying excess weight and an anemia, are obvious; but if weight gain and hypertension are associated, pre-eclampsia should be suspected Postviral and Chronic Fatigue Syndromes A particularly dif cult problem arises in the patient who complains of severe fatigue for many months or even years after a bout of infectious mononucleosis or some other viral illness This has been appropriately called the postviral fatigue syndrome The majority of patients are women between 20 and 40 years of age, but there are undoubtedly young men with the same illness.

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A few such patients were found to have unusually high titers of antibody to EBV, which suggested a causal relationship and gave rise to terms such as the chronic infectious mononucleosis or chronic EBV syndrome (Strauss et al) However, subsequent studies made it clear that a vast majority of patients with complaints of chronic fatigue have neither a clear-cut history of infectious mononucleosis nor serologic evidence of such an infection (Strauss; Holmes et al) In some of these patients the fatigue state has allegedly been associated with obscure immunologic abnormalities simliar to those attributed (spuriously) to silicone breast implants or minor trauma The currently fashionable designation for these and other abstruse states of persistent fatigue is the chronic fatigue syndrome.

Block comments are multiple lines that start with a slash and an asterisk (/*) and end with the reverse (*/). These are useful if you have lengthy comments that run on for several lines. As the general principle is that more comments are better than fewer, you will probably be making extensive use of this type of comment. Here is an example:

Some perspective is provided by the recognition that a malady of this precise nature, under many different names, has long pervaded postindustrial western society, as described by Shorter in an informative history of the chronic.

Our next strategy for coping with NP-completeness is inspired by evolution (which is, after all, the world s best-tested optimization procedure) by its incremental process of introducing small mutations, trying them out, and keeping them if they work well. This paradigm is called local search and can be applied to any optimization task. Here s how it looks for a minimization problem. let s be any initial solution while there is some solution s in the neighborhood of s for which cost(s ) < cost(s): replace s by s return s On each iteration, the current solution is replaced by a better one close to it, in its neighborhood. This neighborhood structure is something we impose upon the problem and is the central design decision in local search. As an illustration, let s revisit the traveling salesman problem.

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