Assessment of fatigue in patients with ankylosing spondylitis: a psychometric analysis

OBJECTIVES

To investigate whether the single-item fatigue question of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Multidimensional Fatigue Inventory (MFI) are appropriate instruments to measure fatigue in ankylosing spondylitis (AS); to identify factors that influence fatigue in AS; and to assess how fatigue in all its aspects is associated with quality of life in AS.

METHODS

A total of 812 patients with AS were included. Patients completed questionnaires on disease activity (BASDAI), functional ability (Bath Ankylosing Spondylitis Functional Index [BASFI]), global well-being (Bath Ankylosing Spondylitis Global Score [BAS-G]), overall perceived health (EuroQoL visual analog scale), and quality of life (Ankylosing Spondylitis Quality of Life questionnaire, and Short Form 36 [SF-36]). Patients were dichotomized into a F+ group (fatigue = major symptom) if the BASDAI fatigue score was > 5.0 and a F- group (fatigue = minor symptom) if the fatigue score was < 5.0. Reproducibility was assessed with intraclass correlation coefficients, and responsiveness was calculated according to 3 different methods. Logistic regression analysis was used to determine which factors were associated with fatigue. Multiple regression analysis was used to investigate whether fatigue contributes in explaining quality of life.

RESULTS

Fifty-three percent of the patients were assigned to the F+ group. They scored significantly worse compared with the F- group with respect to each dimension of the MFI and to all other questionnaires studied (all P < 0.001). The BASDAI fatigue question, as well as each separate dimension of the MFI, showed moderate to good reproducibility (0.57-0.75) and responsiveness (0.23-0.96). Fatigue was, in the opinion of the patients, highly associated with pain (70% of patients) and stiffness (54% of patients). Logistic regression analysis showed that scores on BASDAI, BASFI, BAS-G, and mental health status (SF-36) were independently associated with fatigue (R(2) = 0.52). Multiple regression analysis showed that scores on the BASDAI fatigue question were significantly associated with quality of life. With the 5 MFI dimensions as explanatory variables, different aspects of fatigue were associated with different domains of quality of life.

CONCLUSIONS

Fatigue as a major symptom of AS can effectively be measured with either a single-item question on the intensity of fatigue or with the MFI. The MFI, however, provides more insight into specific dimensions of fatigue. Fatigue appears to be associated with the level of disease activity, functional ability, global well-being, and mental health status. In addition, fatigue negatively influences different aspects of quality of life.

Cachexia and asthenia in cancer patients

Over the past 10 years, there have been major advances in the understanding of cancer cachexia and asthenia. These common complications of cancer are now thought to be the consequences of complex interactions between host, tumour, and psychosocial factors. Cachexia and asthenia commonly coexist, but they can occur independently of each other. Recently identified tumour-derived factors cause lipolysis and protein catabolism. Cytokines produced by the host in response to tumour presence cause metabolic abnormalities, which result in decreased protein and lipid synthesis, increased lipolysis, and anorexia. Many other factors contribute to asthenia, such as anaemia, autonomic failure, and muscular abnormalities. Future research should clarify optimum management. The way forward seems to lie in a multidimensional approach with combined therapy to manage both cancer cachexia and asthenia.

Mixed cryoglobulinemia in hepatitis C patients. GERMIVIC

Cryoglobulins are immunoglobulins that persist in the serum, precipitate with cold temperature and resolubilize when rewarmed. Types II and III are mixed cryoglobulins (MC), composed of different immunoglobulins, with a monoclonal component in type II and only polyclonal immunoglobulins in type III. Mixed cryoglobulins are associated with connective-tissue disease, malignant hematological disorder (type B lymphoproliferation) or obvious infectious process. Mixed cryoglobulinemia syndrome is characterized by the clinical triad of purpura, arthralgia and asthenia associated with type II or type III MC. The disorder is the consequence of an immune-complex-type vasculitis as supported by clinical features, analysis of the cryoglobulins, the usually depressed level of complement during the active phase of the disease, and the deposition of immunoglobulins and complement in the lesions. Such cryoglobulinemia vasculitis may involve numerous organs, particularly the peripheral nervous system and the kidneys. MC is frequently associated with clinical and biological evidence of liver disease. There has been some controversy about which comes first, MC or chronic liver disease, but it seems fairly clear that MC is often a manifestation of underlying chronic active or persistent hepatitis. In MC patients, the hepatotropic antigen(s) capable of triggering production of antibodies which can later form immune complexes has been sought for many years. In the last ten years, numerous studies have demonstrated that infection with hepatitis C virus is involved in the pathogenesis of most mixed cryoglobulinemia. This review analyzes the main published data on hepatitis C virus-mixed cryoglobulinemia, the role of liver alterations, the predictive factors associated with MC production in HCV patients and its symptomatic nature or not, and the different types of vasculitis associated with HCV chronic infection.

[The main clinico-neurological syndromes of prolonged hypokinesia]

Based on analysis of the nature and course of disorders in 81 volunteers as the sequel to strict horizontal (0 degree) or head-down (-4 degrees to -6 degrees) bed rest (hypokinesia) from seven days up to six months, neurological phenomenology of the following clinical syndromes was described: "acute" hemodynamics deviations, physical and thermal discomfort, astheno-neurotic developments, autonomous vascular dysfunction and trophic disturbances, neuromuscular disorders, statokinetic disorders, algesia, and degraded ability to do physical performance tests. Each of the above syndromes became perceptible at certain phases of bed rest, progressed as the time of hypokinesia grew and sharply aggravated early in the readaptation period on regaining the vertical posture and peaked during physical testing. Despite of the variety of physical exercises and supportive medicaments used during six months of bed rest, recovery of the health disorders took no less than two months of extensive therapeutic/rehabilitative treatment.

[Muscle, fatigue, sports and infection]

PURPOSE

Skeletal muscle can be considered as motors which convert chemical energy into mechanical energy. We can evaluate the intracellular pH and energy state of phosphate-containing metabolites in skeletal muscle of patients complaining fatigue or asthenia, using phosphorus MRS.

MAIN POINTS

Acute infectious disease and extreme endurance exercise may induce a loss of oxidative capacity of muscle tissue. Muscle fatigue is not due only to an insufficient supply of ATP to the energy consuming mechanisms. Phosphorus MRS show a muscle production of toxic metabolites such as lactates, protons and ammonia. These metabolic features induced excessive intracellular acidosis of skeletal muscle and systemic hyperammonia, responsible of fatigue and asthenia.

PERSPECTIVES

Reversal of the excessive acidosis and improvement of the capacity for oxidative ATP synthesis might help to relieve the symptoms of exhaustion/fatigue in these patients.

[Role of autonomic nervous system in pathogenesis and clinical manifestation of arterial hypertension in Icenko-Cushing disease]

AIM

To study the role of autonomic nervous system (ANS) in pathogenesis and clinical symptoms of arterial hypertension (AH) in Icenko-Cushing disease (ICD).

MATERIALS AND METHODS

Clinical and paraclinical parameters (vegetative reflexes, special tables, 10 words memory and Spilberg's tests, ECG, electroencephalography, computed tomography, MR-tomography, hormonal status) were studied in 48 ICD patients before and after treatment (adenomectomy, irradiation of the hypophysis, adrenalectomy, parlodel, chlotidin chemotherapy).

RESULTS

94.5% of patients with active ICD had blood hypertension and vegetovascular asthenia. There was a trend to cerebrovascular impairment. In spite of biochemical and clinical ICD remission lipothemia persisted in many patients.

CONCLUSION

Pathogenesis of blood hypertension in ICD is related to hypersecretion of ACTH and corticosteroids but further progress of the disease depends on phenotypic features of autonomic nervous system and developing defects of CNS.

[Changes in brain memory functions as affected by a constant magnetic field]

Effects of CMF on memory processes in adult volunteers (non-sleep us hypnotic condition) has been studied at laboratory and clinical conditions. The results point out that CMF changes the interhemispheric relations and result in memory malfunction. The malfunction of memory activity in volunteers after action of CMF was influenced by two factors: magnetic field position under different brain areas and functional status of volunteers: awake or hypnotic.

On the intercorrelation of some frequency and amplitude parameters of the human EEG and its functional significance. Communication II: neurodynamic imbalance in endogenous asthenic-like disorders

In 67 borderline psychiatric patients suffering from schizotypal/slowly developing schizophrenic disorders and 18 patients suffering from cyclothymia, the factor structure of the period (interval-amplitude) parameters of the EEG proved to be similar to that obtained in normal subjects during mental activity and reported in part I (Lazarev, Int. J. Psychophysiol., 28 (1998) 77-98). However, 51 patients with schizotypal disorders with a predominance of asthenic-like symptomatology, characterized by mild thought disorders with difficulty in focusing attention, were distinguished from normal subjects, cyclothymic patients and other patients of schizotypy without well-defined asthenic symptoms by significantly increased values of EEG Factor II which was positively related to the index-presence in epoch, frequency and regularity of low-amplitude beta-waves, and reduced values of an EEG Factor III which was positively correlated with mean alpha-period and theta-index. According to normative data (part I; Lazarev, Int. J. Psychophysiol., 28 (1998) 77-98), this probably reflects a neurodynamic imbalance between an excess of 'cortical excitation' (Factor II) and a deficit of 'active selective inhibition' (Factor III). This imbalance appears to be opposite to the changes in values of these factors found in normal subjects during focusing attention and motor automation, when compared with relaxed wakefulness. The functional properties of Factors II and III ascribed on the basis of psychological testing suggest that such an imbalance could reflect a predominance of successively organised associative mental processes over the selective inhibition of irrelevant associations. This could cause difficulties in voluntary attention, mental automation and in the performance of simultaneous mental operations. In most cases, there was no difference in Factor I which was positively related to the index, amplitude and regularity of alpha-activity and wave amplitudes in other bands, and negatively related to the indices and mean periods of delta- and theta-waves, the factor presumed to depict 'general activation'.

Preliminary results of a study assessing asthenia and related psychological and biological phenomena in patients with advanced cancer

Asthenia is a very common symptom of patients with advanced cancer, but its investigation is hindered by a lack of suitable validated measuring instruments. The goal of the present study was to construct and validate a questionnaire for the study of asthenia in cancer patients, as well as to establish correlations with other symptoms and physiological and biochemical parameters. A group of 31 patients with advanced cancer and a control group of 30 healthy volunteers were examined. The proposed questionnaire, based on visual analogue scales, questions with categorical answers and on the hospital anxiety and depression scale was validated by comparing results of the patient and control groups, by the test/retest method and by comparison with the evaluation of an observer. Correlation with various physiological and biochemical parameters was performed. The questionnaire distinguished well among the patients and control groups. VAS of asthenia proved quite stable over a period of 5 days. Correlations of asthenia with lack of appetite, the hospital anxiety and depression scale, weight, heart rate and serum cortisol levels could be established. No significant correlation between asthenia and various serum markers of inflammation and cytokines, including C-reactive protein, tumour necrosis factor, interleukin-1, and interleukin-2 receptors, could be found. The proposed questionnaire for evaluation of asthenia could be validated in a patient sample of limited size and a simplified questionnaire based on visual analogue scales is being developed for further investigations.

[The characteristics of perception under emotionally stressed goal-directed activity]

The taste and visual analysers were studied during the tests period in students. The effect of emotions on the sensory sphere was shown to be determined by their sign and their sthenic or asthenic character. Both positive and negative emotions seem to be able to develop in asthenic or sthenic ways.

In vitro polymorphonuclear neutrophil function in surgical patients does not correlate with anergy but with "activating" processes such as sepsis or trauma

We studied 199 preoperative patients admitted for esophagogastric, gastric, colonic, or rectal resections, 132 patients with severe blunt trauma, 180 surgical intensive care unit patients with major sepsis, and 95 laboratory controls in order to clarify the role of polymorphonuclear neutrophil (PMN) adherence and chemotaxis to outcome. Patients were also stratified by the delayed-type hypersensitivity response to five ubiquitous antigens. PMN adherence and PMN chemotaxis were not different in preoperative reactive or anergic patients and were equal to the control values, whereas both reactive patients and anergic patients showed altered PMN function after trauma or sepsis. There was no difference in PMN adherence or chemotaxis between patients who died and those who lived. Multiple logistic regression analysis showed that patient age, delayed-type hypersensitivity, and admission serum albumin level, not PMN adherence or chemotaxis, were significantly related to septic mortality. We concluded that altered circulating PMN adherence and chemotaxis is seen in all patients after an "activation" event such as trauma or sepsis. This is a nonspecific immune alteration not related to specific immune events such as delayed-type hypersensitivity; it does not correlate with patient outcome and should not be used as a predictive variable.

Association between asthenia and nutritional status, lean body mass, anemia, psychological status, and tumor mass in patients with advanced breast cancer

Sixty-four consecutive patients with advanced breast cancer were included in a study designed to determine the prevalence of asthenia and its association with other clinical features. The Asthenia Score (AS, the average of four tests designed by our group to assess asthenia) was 59 +/- 9 for patients versus 88 +/- 7 for a group of 68 normal controls (p less than 0.001). Twenty-six patients (41%) scored below the tenth percentile of normal controls and were considered asthenics. AS was correlated with depression and the general severity index of the SCL-90 R test. No association was found between AS and nutritional status, lean body mass, tumor mass, anemia, or type of treatment. We conclude that asthenia is a frequent symptom in patients with advanced breast cancer, which, in our series, showed independent correlations only with psychological distress.

[The importance of individualized physical training in the rehabilitation of patients with arterial hypotension]

Essential hypotension patients whose 2-year program of rehabilitation included continuous physical training according to individual multifactorial programs or relevant training combined with drug therapy showed more favourable clinical response. Threshold muscular load and everyday motor activity rose more significantly when compared to those in patients who received chemotherapy alone.

[The preoperative mental state]

In four studies psychological and psychophysiological correlations to anesthesiologically important factors were investigated. The most important preoperative emotions are anxiety, depression and asthenia. These emotions are part of the preoperative stress response. It was investigated which factors are correlated to these emotions and how these emotions correlate to physiological parameters, important in anesthesia. Sex, age, the quality of former experience of anesthesia and suffering of a chronic disease influence the degree of preoperative emotional stress. Cancer or the suspect of cancer increase preoperative anxiety. The preoperative psychological state correlates to blood pressure, heart rate and P-cortisol as well as to complications in anesthesia. There are two psychophysiological risk groups: Patients in a bad psychological state and patients in a good psychological state. Patients in the mean group have the best prognosis. Differences depending on the emotions anxiety depression and asthenia are described and discussed.

Association of mitral-valve prolapse with low body-weight and low blood pressure

Subjects with mitral-valve prolapse (MVP) have been observed to have an asthenic body build. To determine whether body-weight differed between individuals with inherited MVP and normal subjects, 177 relatives of 45 patients with MVP were studied, 35 female and 19 male relatives had MVP, and 51 female and 72 male relatives did not. There was no difference in mean height between relatives with and without MVP, but those with MVP weighed significantly less. Blood pressure was also significantly lower in relatives with MVP than in normal relatives. It is suggested that the lower blood pressure and the possible beneficial effects of lower weight on other cardiovascular risk factors may provide a selective advantage to carriers of the MVP gene, explaining its high prevalence in the general population. These findings may provide the first example of a common inherited condition which is systematically associated with changes in body-weight and blood pressure.