Tag: 2002

Review: behavioural interventions show the most promise for chronic fatigue syndrome

Comment on: Interventions for the treatment and management of chronic fatigue syndrome: a systematic review. [JAMA. 2001]

 

QUESTION: In patients with chronic fatigue syndrome (CFS), what is the effectiveness of evaluated interventions?

Data sources: Published and unpublished studies in any language were identified by searching 19 databases, including Medline, EMBASE/Excerpta Medica, PsycLIT, ERIC, Current Contents, and the Cochrane Library (to 2000); the internet was searched using a meta-search engine; references of retrieved articles were scanned; and individuals and organisations were contacted through a website dedicated to this review and through members of 2 advisory panels.

Study selection: Studies were selected if they were randomised controlled trials (RCTs) or controlled clinical trials of any intervention used in the treatment or management of CFS in adults or children. Studies in which diagnoses were based on another syndrome with criteria similar to CFS, such as myalgic encephalomyelitis, chronic fatigue immune deficiency syndrome, or chronic Epstein-Barr virus infection, were included, but studies of fibromyalgia were not.

Data extraction: Data were extracted on study validity (randomisation and allocation concealment [RCTs], control group appropriateness and adjustment for confounders [controlled studies], baseline comparability of groups, blinding, follow up, drop outs, objectivity of outcome assessment, analysis, sample size, and cointerventions); intervention; diagnostic criteria; duration of follow up; and outcomes (psychological, physical, quality of life and health status, physiological, and resource use).

Main results: 44 studies (n=2801; age range 11–87 y, 71% women) were included (32 studies of adults, 1 of children, and 2 of adults and children; 9 studies did not give age information). 31 different interventions were grouped by type of intervention (behavioural, immunological, pharmacological, supplements, complementary or alternative, and other interventions). 36 studies were RCTs. 18 trials (41%) showed an overall beneficial effect of the intervention (≥1 clinical outcome improved). The results from the RCTs are shown in the table. Cognitive behavioural therapy (CBT) and graded exercise therapy (GET) had beneficial effects. Overall evidence from the other interventions was inconclusive.

 

Source: Kinsella P. Review: behavioural interventions show the most promise for chronic fatigue syndrome. Evid Based Nurs. 2002 Apr;5(2):46. http://ebn.bmj.com/content/5/2/46.long (Full article)

 

 

Caring for a relative with chronic fatigue syndrome: difficulties, cognition and acceptance over time

Abstract:

The present study explored the difficulties experienced by carers of chronic fatigue syndrome (CFS) sufferers, their cognitions, and their efforts to accept the illness. Semi-structured interviews were conducted with 17 carers to study these issues, retrospectively, over three stages: before the diagnosis of CFS, shortly after the diagnosis, and at present.

Surprisingly, the results suggested that carers, several of them absent from home during the day, felt that their lives were only minimally constrained by the illness. Nevertheless, all carers reported specific coping efforts to manage both the illness and their own distress, and indicated that they learned to accept the illness over time. However, acceptance appeared to be a form of resignation rather than a positive appreciation of the illness.

In light of the uncertainties surrounding the origin of CFS and carers’ apparent confusion, the results obtained in the present study are significant in that they increase our understanding of CFS carers’ quality of life, their efforts to cope with the illness, and the physical and emotional help they may provide to the sufferer. Such information can be usefully employed in the increasing development of counselling interventions and instrumental support networks that involve both sufferers and their carers.

 

Source:  Ax S, Gregg VH, Jones D.  Caring for a relative with chronic fatigue syndrome: difficulties, cognition and acceptance over time. J R Soc Promot Health. 2002 Mar;122(1):35-42. http://www.ncbi.nlm.nih.gov/pubmed/11989141

 

Antiviral pathway activation in chronic fatigue syndrome and acute infection

Comment on: Antiviral pathway activation in patients with chronic fatigue syndrome and acute infection. [Clin Infect Dis. 2001]

 

SIR—We read the very engaging report by Gow et al. [1] with the utmost interest. However, we feel that this article raises more questions than clear-cut answers regarding the hypothesis that motivated the study—that is, that the previously reported activation of the antiviral pathway in chronic fatigue syndrome (CFS) might be linked to infection rather than to CFS specifically. To verify their hypothesis, Gow and colleagues used PCR to measure the genetic expression of 3 IFN-regulated genes—namely, the latent ribonuclease (RNase L), RNA-regulated protein kinase (PKR), 2,5 synthetase, and the RNase L inhibitor (RLI)—in patients with acute infection (in their study, severe gastroenteritis; group 1), patients with CFS (group 2), and healthy control subjects (group 3).

First, surprisingly enough, although they recognized that acute infection is supposed to induce the expression of the genes selected for their study (see figure 1 of [1]), Gow and colleagues failed to find any significant increase in the expression of 2 major genes (RNase L and 2,5 synthetase) in group 1, as compared with groups 2 and 3; they observed only increased mRNA for PKR and RLI. Although it is recognized that genetic expression of PKR, RNase L, and 2,5 synthetase is under the control of interferon, RLI is definitely not [2]. Upregulation of RLI genetic expression with a normal genetic expression of both 2,5 synthetase and RNase L (although PKR is overexpressed!) during acute infection, as was observed in the study of Gow et al. [1], would indicate not only that RNase L is not activated (normal expression of RNase L and, more importantly, of 2,5 synthetase), but that it is further inhibited by an overexpressed RLI [2]. Such a scenario, if verified, would be in complete disagreement with the current understanding of the IFN pathway [3]. Therefore, we cannot help but wonder how Gow and colleagues reconcile their observations with the acute infection status of study group 1. In our view, this inconsistency severely undermines their conclusions.

You can read the rest of this comment here:  http://cid.oxfordjournals.org/content/34/10/1420.long

 

Source: De Meirleir K, Suhadolnik RJ, Lebleu B, Englebienne P. Antiviral pathway activation in chronic fatigue syndrome and acute infection. Clin Infect Dis. 2002 May 15;34(10):1420-1; author reply 1421-2. http://cid.oxfordjournals.org/content/34/10/1420.long (Full article)

 

Generation of classification criteria for chronic fatigue syndrome using an artificial neural network and traditional criteria set

Abstract:

OBJECTIVE: The definition of chronic fatigue syndrome (CFS) is still disputed and no validated classification criteria have been published. Artificial neural networks (ANN) are computer-based models that can help to evaluate complex correlations. We examined the utility of ANN and other conventional methods in generating classification criteria for CFS compared to other diseases with prominent fatigue, systemic lupus erythematosus (SLE) and fibromyalgia syndrome (FMA).

PATIENTS AND METHODS: Ninety-nine case patients with CFS, 41 patients with SLE and 58 with FMA were recruited from a generalist outpatient population. Clinical symptoms were documented with help of a predefined questionnaire. The patients were randomly divided into two groups. One group (n = 158) served to derive classification criteria sets by two-fold cross-validation, using a) unweighted application of criteria, b) regression coefficients, c) regression tree analysis, and d) artificial neural networks in parallel. These criteria were validated with the second group (n = 40).

RESULTS: Classification criteria developed by ANN were found to have a sensitivity of 95% and a specificity of 85%. ANN achieved a higher accuracy than any of the other methods.

CONCLUSION: We present validated criteria for the classification of CFS versus SLE and FMA, comparing different classification approaches. The most accurate criteria were derived with the help of ANN. We therefore recommend the use of ANN for the classification of syndromes with complex interrelated symptoms like CFS.

 

Sour ce: Linder R, Dinser R, Wagner M, Krueger GR, Hoffmann A. Generation of classification criteria for chronic fatigue syndrome using an artificial neural network and traditional criteria set. In Vivo. 2002 Jan-Feb;16(1):37-43. http://www.ncbi.nlm.nih.gov/pubmed/11980359

 

Dry eyes and mouth syndrome–a subgroup of patients presenting with sicca symptoms

Abstract:

OBJECTIVE: To evaluate the characteristics of patients presenting with symptoms suggestive of Sjögren’s syndrome (SS) but failing to satisfy diagnostic criteria.

METHODS: Clinical, serological and histological data were collected on 34 patients presenting with dry eyes and/or mouth who did not satisfy the Vitali criteria for the diagnosis of SS. They were compared with 136 patients with primary SS, 38 patients with secondary SS, and 13 patients without SS. Questionnaires on symptoms from each group were compared with 43 healthy controls.

RESULTS: The 34 patients who did not satisfy the diagnostic criteria for SS or any other connective tissue disease were designated dry eyes and mouth syndrome (DEMS). Their demography including age was similar to that of a primary SS group and there was no more atrophy seen on their biopsies compared with SS and non-SS controls. They scored highly on visual analogue scales of symptoms but had few objective signs. All were negative for anti-Ro and anti-La although the prevalence of antinuclear antibodies (19%) was increased compared with a normal population. There was no excess of SS-associated tissue types.

CONCLUSION: There was no evidence that age, salivary gland atrophy or subclinical SS accounted for the symptoms in DEMS. Most of the patients fitted into a spectrum of disease which tended more towards fibromyalgia and/or chronic fatigue syndrome.

Comment in: Dry eyes and mouth syndrome or sicca, asthenia and polyalgia syndrome? [Rheumatology (Oxford). 2003]

 

Source: Price EJ, Venables PJ. Dry eyes and mouth syndrome–a subgroup of patients presenting with sicca symptoms. Rheumatology (Oxford). 2002 Apr;41(4):416-22. http://rheumatology.oxfordjournals.org/content/41/4/416.long (Full article)

 

 

 

The case definition of chronic fatigue syndrome

Abstract:

The 1994 case definition of chronic fatigue syndrome is widely used not only for diagnosis but also for clinical and laboratory-based observations of this clinical entity. The criteria for the 1994 case definition are based primarily on symptoms and not on physical signs or chemical or immunological tests. This situation has resulted in conflicting clinical and laboratory observations that in all likelihood is due to different populations of patients being studied in different centers.

Based on some of the recent publications, there appears to be an emerging picture of this disease entity that we propose could be used to subgroup chronic fatigue syndrome into four different subclasses. These subclasses would consist of chronic fatigue with primarily nervous system disorders such as impaired memory or concentration and headache, chronic fatigue with primarily endocrine system disorders such as unrefreshing sleep and postexertional malaise, chronic fatigue with musculoskeletal system disorders such as muscle pain and joint pain, and chronic fatigue with immune system/infectious disorders such as sore throat and tender lymph nodes.

It is suggested that if clinical and laboratory-based studies on chronic fatigue syndrome were conducted on more homogeneous subgroups of patients, the data from one center to the other might not be as conflicting and more insights can be shed on the nature of this clinical condition.

 

Source: Tan EM, Sugiura K, Gupta S. The case definition of chronic fatigue syndrome. J Clin Immunol. 2002 Jan;22(1):8-12. http://www.ncbi.nlm.nih.gov/pubmed/11958593

 

Editorial on CFS was biased, inaccurate, and misleading

EDITOR—As a member of the chief medical officer’s working group on chronic fatigue syndrome, I consider that Straus has failed to appreciate the difficulties of deciding what constitutes evidence in an illness as uncertain and heterogeneous as this.1 He also misunderstood, or took out of context, some of the key conclusions and recommendations in the chief medical officer’s report.

Although it was agreed that evidence should not just be limited to the results of randomised controlled trials, the findings of the York systematic review were frequently cited. It was therefore disingenuous of Straus to state that information from this review did not influence the report’s conclusions about a wide range of therapeutic interventions. It did.

Equally, it would have been a serious omission if the report had failed to refer to the feedback from patients contained in three large surveys on attitudes to management, as well as two events where patients and carers met with the working group. All three surveys concluded that graded exercise as is currently being done made more people worse than any other intervention. Pacing, however, was found to be beneficial by around 90% of respondents. By dismissing such views as anecdote, Straus fails to appreciate that the Department of Health is encouraging patients to enter into a therapeutic relationship with the medical profession in the management of chronic conditions such as this.2

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122848/

 

Source: Shepherd C. Editorial on CFS was biased, inaccurate, and misleading. BMJ. 2002 Apr 13;324(7342):914. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122848/ (Full article)

 

Role of pathological delayed-type hypersensitivity in chronic fatigue syndrome: importance of the evaluation of lymphocyte activation by flow cytometry and the measurement of urinary neopterin

Abstract:

Chronic fatigue syndrome or benign myalgic encephalomyelitis has been extensively described and investigated. Although numerous immunological abnormalities have been linked with the syndrome, none have been found to be specific.

This article describes the detection of delayed-type hypersensitive responses to certain common environmental antigens in almost fifty per cent of patients with this syndrome. Such hypersensitivity can be detected by the intradermal administration of antigens derived from commensal organisms like the yeast Candida albicans, and then monitoring for a systemic reaction over the following six to forty eight hours. This approach can be consolidated by performing lymphocyte activation tests in parallel and measuring in vitro T-cell activation by Candida albicans antigens by three-colour flow cytometry based on CD3, CD4 and either CD69 or CD25.

Another useful parameter is the kinetics of neopterin excretion in the urine over the course of the skin test. The results showed that the intensity of the DTH response correlated with the number of T-cells activated in vitro. Various factors have been implicated in the fatigue of many patients, notably lack of sleep. However, it remains difficult to establish causality in either one direction or the other. This work is in the spirit of a multifactorial approach to the group of conditions referred to as “chronic fatigue syndrome”.

 

Source: Brunet JL, Fatoohi F, Liaudet AP, Cozon GJ. Role of pathological delayed-type hypersensitivity in chronic fatigue syndrome: importance of the evaluation of lymphocyte activation by flow cytometry and the measurement of urinary neopterin. Allerg Immunol (Paris). 2002 Feb;34(2):38-44. [Article in French] http://www.ncbi.nlm.nih.gov/pubmed/11933752

 

Evaluating attributions for an illness based upon the name: chronic fatigue syndrome, myalgic encephalopathy and Florence Nightingale disease

Abstract:

In recent years, considerable discussion has occurred about stigma surrounding the name given to an illness currently known as chronic fatigue syndrome (CFS). Although patients and medical personnel have expressed varying opinions on this issue, no studies have evaluated how beliefs about the illness change based upon the type of name used for diagnostic purposes. Proposals have been put forth to rename the illness with an eponym (a famous patient’s or researcher’s name) or with a less trivial sounding, more medically based type of name.

In this study, attributions about CFS were measured in three groups of medical trainees. All groups read the same case study of a person with classic symptoms of chronic fatigue syndrome, with the only difference being in the type of name given. Trainees then were asked to provide attributions about certain aspects of the illness, including its cause, severity, and prognosis.

Results suggested that, across name conditions, most trainees appeared to consider the symptom complex of CFS a serious illness resulting in poor quality of life. In addition, findings indicated that the name, chronic fatigue syndrome, may be regarded less seriously than the Myalgic Encephalopathy name with respect to some important aspects of the illness. In this study, specialty of medical trainee also played a role in how the illness was perceived.

 

Source: Jason LA, Taylor RR, Plioplys S, Stepanek Z, Shlaes J. Evaluating attributions for an illness based upon the name: chronic fatigue syndrome, myalgic encephalopathy and Florence Nightingale disease. Am J Community Psychol. 2002 Feb;30(1):133-48. http://www.ncbi.nlm.nih.gov/pubmed/11928774

 

Chronic fatigue syndrome: evaluation and treatment

Abstract:

Severe fatigue is a common complaint among patients. Often, the fatigue is transient or can be attributed to a definable organic illness. Some patients present with persistent and disabling fatigue, but show no abnormalities on physical examination or screening laboratory tests. In these cases, the diagnosis of chronic fatigue syndrome (CFS) should be considered. CFS is characterized by debilitating fatigue with associated myalgias, tender lymph nodes, arthralgias, chills, feverish feelings, and postexertional malaise. Diagnosis of CFS is primarily by exclusion with no definitive laboratory test or physical findings. Medical research continues to examine the many possible etiologic agents for CFS (infectious, immunologic, neurologic, and psychiatric), but the answer remains elusive. It is known that CFS is a heterogeneous disorder possibly involving an interaction of biologic systems. Similarities with fibromyalgia exist and concomitant illnesses include irritable bowel syndrome, depression, and headaches. Therefore, treatment of CFS may be variable and should be tailored to each patient. Therapy should include exercise, diet, good sleep hygiene, antidepressants, and other medications, depending on the patient’s presentation.

Comment in:

Differential diagnosis for chronic fatigue syndrome. [Am Fam Physician. 2003]

Chronic fatigue syndrome and depression. [Am Fam Physician. 2002]

 

Source: Craig T, Kakumanu S. Chronic fatigue syndrome: evaluation and treatment. Am Fam Physician. 2002 Mar 15;65(6):1083-90. http://www.aafp.org/afp/2002/0315/p1083.html (Full article)