Comparison of the effects of acetyl l-carnitine and amantadine for the treatment of fatigue in multiple sclerosis: results of a pilot, randomised, double-blind, crossover trial

Fatigue after liver transplantation: effects of a rehabilitation program including exercise training and physical activity counseling

BACKGROUND

It is hypothesized that increasing physical fitness and daily physical activity can lead to a reduction in fatigue. However, standard medical care following liver transplantation seldom includes rehabilitation that focuses on physical fitness and physical activity.

OBJECTIVE

The aim of this study was to explore whether a rehabilitation program can reduce fatigue in recipients of liver transplants. Furthermore, effects on physical fitness, physical activity, and cardiovascular risk were studied, and adherence, satisfaction, and adverse events were assessed.

DESIGN

This was an uncontrolled intervention study.

SETTING

The study took place in an outpatient rehabilitation clinic.

PATIENTS

Eighteen recipients of a liver transplant who were fatigued participated in a 12-week rehabilitation program including physical exercise training and counseling on physical activity. The primary outcome measure was fatigue. Other outcome measures were: aerobic capacity, muscle strength, body fat, daily physical activity, lipid profile, and glycemic control. All measurements were performed before and after the rehabilitation program. Adherence, satisfaction, and adverse events were registered.

RESULTS

After the program, participants were significantly less fatigued, and the percentage of individuals with severe fatigue was 22% to 53% lower than before the program. In addition, aerobic capacity and knee flexion strength were significantly higher, and body fat was significantly lower after the program. Participants were able to perform physical exercise at the target training intensity, no adverse events were registered, and attendance (93%) and mean patient satisfaction (8.5 out of 10, range=7-10) were high.

LIMITATIONS

No control group was used in the study.

CONCLUSIONS

A rehabilitation program consisting of exercise training and physical activity counseling is well tolerated and seems promising in reducing fatigue and improving fitness among recipients of liver transplants.

Meta-analysis of three different types of fatigue management interventions for people with multiple sclerosis: exercise, education, and medication

Fatigue is a common symptom of multiple sclerosis (MS) with negative impacts extending from general functioning to quality of life. Both the cause and consequences of MS fatigue are considered multidimensional and necessitate multidisciplinary treatment for successful symptom management. Clinical practice guidelines suggest medication and rehabilitation for managing fatigue. This review summarized available research literature about three types of fatigue management interventions (exercise, education, and medication) to provide comprehensive perspective on treatment options and facilitate a comparison of their effectiveness. We researched PubMed, Embase, and CINAHL (August 2013). Search terms included multiple sclerosis, fatigue, energy conservation, Amantadine, Modafinil, and randomized controlled trial. The search identified 230 citations. After the full-text review, 18 rehabilitation and 7 pharmacological trials targeting fatigue were selected. Rehabilitation interventions appeared to have stronger and more significant effects on reducing the impact or severity of patient-reported fatigue compared to medication. Pharmacological agents, including fatigue medication, are important but often do not enable people with MS to cope with their existing disabilities. MS fatigue affects various components of one's health and wellbeing. People with MS experiencing fatigue and their healthcare providers should consider a full spectrum of effective fatigue management interventions, from exercise to educational strategies in conjunction with medication.

Serum carnitine level and its associated factors in patients with chronic viral hepatitis

ABSTRACT: 

Aim: Serum carnitine level and its associated factors have been evaluated in patients with chronic viral hepatitis. Methods: Patients with confirmed chronic viral hepatitis based on the serological markers and liver biopsy were included. In total, 86 volunteers and 86 patients with chronic viral hepatitis completed the study. Demographic data, type of treatment regimen and nutritional status of the patients were recorded and one blood sample was collected from each patient after an overnight fasting. A double antibody sandwich ELISA kit was used to measure carnitine serum level. Results: Mean ± standard deviation of serum carnitine level in the case and control groups were 34.3 ± 15.3 and 55.7 ± 28.4 μmol/l, respectively (p = 0.001). Regarding carnitine deficiency definition, 64 out of 86 patients (74.4%) and 21 out of 86 (24.5%) healthy individuals suffered from carnitine deficiency (p < 0.001). Carnitine dietary intake was significantly lower (p < 0.001). Compared with patients with chronic hepatitis C infection, a more severe form of carnitine deficiency was detected in patients with chronic hepatitis B infection (18.39 ± 15.68 μmol/l vs 42.30 ± 32.92 μmol/l; p = 0.03). In addition, serum carnitine level (41.1 ± 14.8 μmol/l) was significantly higher in the cirrhotic than noncirrhotic patients (31.60 ± 13.2 μmol/l; p = 0.04). Conclusion: Although the cirrhotic patients had higher serum carnitine level compared with noncirrhotic patients, serum carnitine level in the patients with chronic hepatitis was significantly lower than the healthy individuals. Also compared with the defined cut-off point for normal carnitine serum level, carnitine deficiency was common in Iranian patients with chronic hepatitis.

Multiple sclerosis

Multiple sclerosis (MS) is a chronic progressive demyelinating disease of the central nervous system. Common manifestations include paresthesias, diplopia, loss of vision, numbness or weakness of the limbs, bowel or bladder dysfunction, spasticity, ataxia, fatigue, and mental changes. Four main patterns of MS are recognized: relapsing remitting, primary progressive, secondary progressive, and progressive relapsing. The cause of MS is unknown, although it appears to be an autoimmune disease. Much of what is known about MS has been learned from an animal model of the disease, experimental allergic encephalomyelitis.

A multimodal intervention for patients with secondary progressive multiple sclerosis: feasibility and effect on fatigue

BACKGROUND

Multiple sclerosis is an autoimmune disease influenced by environmental factors.

OBJECTIVES

The feasibility of a multimodal intervention and its effect on perceived fatigue in patients with secondary progressive multiple sclerosis were assessed.

DESIGN/SETTING

This was a single-arm, open-label intervention study in an outpatient setting.

INTERVENTIONS

A multimodal intervention including a modified paleolithic diet with supplements, stretching, strengthening exercises with electrical stimulation of trunk and lower limb muscles, meditation, and massage was used.

OUTCOME MEASURES

Adherence to each component of the intervention was calculated using daily logs. Side-effects were assessed from a monthly questionnaire and blood analyses. Fatigue was assessed using the Fatigue Severity Scale (FSS). Data were collected at baseline and months 1, 2, 3, 6, 9, and 12.

RESULTS

Ten (10) of 13 subjects who were enrolled in a 2-week run-in phase were eligible to continue in the 12-month main study. Of those 10 subjects, 8 completed the study and 6 subjects fully adhered to the study intervention for 12 months. Over a 12-month period, average adherence to diet exceeded 90% of days, and to exercise/muscle stimulation exceeded 75% of days. Nutritional supplements intake varied among and within subjects. Group daily average duration of meditation was 13.3 minutes and of massage was 7.2 minutes. No adverse side-effects were reported. Group average FSS scores decreased from 5.7 at baseline to 3.32 (p=0.0008) at 12 months.

CONCLUSIONS

In this small, uncontrolled pilot study, there was a significant improvement in fatigue in those who completed the study. Given the small sample size and completer rate, further evaluation of this multimodal therapy is warranted.

Treatment of symptoms in multiple sclerosis

The current focus regarding treatment of multiple sclerosis (MS) to be on therapies that may alter the course of the disease. Some of the evidence regarding the efficacy of these treatments is based on changes in the appearance of neuroimaging studies of the brain and spinal cord and not on the effect of these treatments on clinical symptomatology. Since most of our patients with MS continue to be symptomatic despite the use of immunomodulating agents, it is important for the treating neurologist to be familiar with treatments for these symptoms, many of which are extremely disabling to the patient. Knowing how to deal with common complaints/symptoms of MS enables us to better practice the art of neurological care.

Pharmacological and drug-free interventions for fatigue in multiple sclerosis

SUMMARY Fatigue in multiple sclerosis is a symptom that is present in up to 95% of patients and has tremendous effects on patients’ quality of life. Often, patients feel impelled to reduce their workload or even to abandon their occupation completely. Not seldomly, these steps lead to social withdrawal and depressive episodes. Although the clinical features and the resulting consequences for patients are well described, objective assessment, quantification of symptom severity and treatment options are still topics of controversial discussion and worldwide accepted methodological approaches have yet to be developed.

The supplementation of acetyl-L-carnitine decreases fatigue and increases quality of life in patients with hepatitis C treated with pegylated interferon-α 2b plus ribavirin

The aim of this study was to evaluate whether supplementation of acetyl-L-carnitine (ALC) to pegylated-interferon-α 2b (Peg-IFN-α 2b) and ribavirin (RBV) improves the health-related quality of life during the treatment for chronic hepatitis C, thereby decreasing the risk of treatment discontinuation. Sixty patients with chronic hepatitis C underwent treatment with Peg-IFN-α 2b + RBV (group A; n = 29) or Peg-IFN-α 2b + RBV + ALC (group B; n = 31) for 12 months. At the end of the study, the comparison between group A and group B showed significant differences in aspartate aminotransferase (AST) (-80.9 versus -110.3; P < 0.001), alanine aminotransferase (-111.6 versus -134.7; P < 0.001), Viremia (-3.26 versus -3.82; P < 0.05), mental health (0 versus 11; P < 0.001), physical functioning (-1 versus 8; P < 0.001), role-physical (1 versus 13; P < 0.001), bodily pain (1 versus 12; P < 0.001), general health (3 versus 12; P < 0.001), vitality (3 versus 13; P < 0.001), social functioning (3 versus 10; P < 0.001), physical fatigue (2.1 versus -5.4; P < 0.001), mental fatigue (-0.7 versus -2.7; P < 0.001), and fatigue severity scale (-3.4 versus -12; P < 0.001). ALC supplementation reduced both mental and physical fatigue, improved health-related quality of life, and, therefore, has the potential to increase patient adherence to the combination regimen. This, in turn, may increase the percentage of patients achieving a sustained virological response.

Carnitine for fatigue in multiple sclerosis

BACKGROUND

Fatigue is reported to occur in up to 92% of patients with multiple sclerosis (MS) and has been described as the most debilitating of all MS symptoms by 28% to 40% of MS patients.

OBJECTIVES

To assess whether carnitine (enteral or intravenous) supplementation can improve the quality of life and reduce the symptoms of fatigue in patients with MS-related fatigue and to identify any adverse effects of carnitine when used for this purpose.

SEARCH METHODS

A literature search was performed using Cochrane MS Group Trials Register (09 September 2011), Cochrane Central Register of Controlled Trials (CENTRAL) "The Cochrane Library 2011, issue 3", MEDLINE (PubMed) (1966-09 September 2011), EMBASE (1974-09 September 2011), and www.clinicaltrials.gov for ongoing trials retrieval. Reference lists of review articles and primary studies were also screened. A hand search of the abstract book of recent relevant conference symposia was also conducted. Personal contact with MS experts and a manufacturer (Source Naturals, United States) of carnitine formulation was contacted to determine if they knew of other clinical trials. No language restrictions were applied.

SELECTION CRITERIA

Full reports of published and unpublished randomized controlled trials and quasi-randomized trials of any carnitine intervention in adults affected by multiple sclerosis with a clinical diagnosis of fatigue associated with multiple sclerosis were included.

DATA COLLECTION AND ANALYSIS

Data from the eligible trials was extracted and coded using a standardized data extraction form and entered into RevMan 5. Discrepancies were to be resolved by discussion with a third reviewer, however this was not necessary.The quality items to be assessed were method of randomization, allocation concealment, blinding (participants, investigators, outcome assessors and data analysis), intention-to-treat analysis and completeness of follow up.

MAIN RESULTS

The search identified one ongoing randomized, placebo-controlled, cross-over trial (expected completion 2013) and one completed randomized, active-comparator, cross-over trial. In the completed study, adult patients with relapsing-remitting and secondary progressive MS were exposed to both acetyl L-carnitine 2 grams daily and amantadine 200 mg daily The effects of carnitine on fatigue are unclear. There was no difference between carnitine and amantadine for the number of patients withdrawing from the study due to an adverse event (relative risk ratio 0.20; 95% confidence interval 0.03 to 1.55) and no patients experienced a serious adverse event in either treatment group. Mortality and quality of life were not reported.

AUTHORS' CONCLUSIONS

There is insufficient evidence that carnitine for the treatment of MS-related fatigue offers a therapeutic advantage over placebo or active comparators. Results of the ongoing trial are eagerly anticipated in order to provide clarity.

Carnitine derivatives: clinical usefulness

PURPOSE OF REVIEW

Carnitine and its derivatives are natural substances involved in both carbohydrate and lipid metabolism. This review summarizes the recent progress in the field in relation to the molecular mechanisms.

RECENT FINDINGS

The pool of different carnitine derivatives is formed by acetyl-L-carnitine (ALC), propionyl-L-carnitine (PLC), and isovaleryl-carnitine. ALC may have a preferential effect on the brain tissue. ALC represents a compound of great interest for its wide clinical application in various neurological disorders: it may be of benefit in treating Alzheimer's dementia, depression in the elderly, HIV infection, chronic fatigue syndrome, peripheral neuropathies, ischemia and reperfusion of the brain, and cognitive impairment associated with various conditions. PLC has been demonstrated to replenish the intermediates of the tricarboxylic acid cycle by the propionyl-CoA moiety, a greater affinity for the sarcolemmal carrier, peripheral vasodilator activity, a greater positive inotropism, and more rapid entry into myocytes. Most studies of the therapeutic use of PLC are focused on the prevention and treatment of ischemic heart disease, congestive heart failure, hypertrophic heart disease, and peripheral arterial disease. ALC and PLC are considered well tolerated without significant side-effects.

SUMMARY

A number of therapeutic effects possibly come from the interaction of carnitine and its derivatives with the elements of cellular membranes.

Objective assessment of motor fatigue in Multiple Sclerosis using kinematic gait analysis: a pilot study

Background

Fatigue is a frequent and serious symptom in patients with Multiple Sclerosis (MS). However, to date there are only few methods for the objective assessment of fatigue. The aim of this study was to develop a method for the objective assessment of motor fatigue using kinematic gait analysis based on treadmill walking and an infrared-guided system.

Patients and methods

Fourteen patients with clinically definite MS participated in this study. Fatigue was defined according to the Fatigue Scale for Motor and Cognition (FSMC). Patients underwent a physical exertion test involving walking at their pre-determined patient-specific preferred walking speed until they reached complete exhaustion. Gait was recorded using a video camera, a three line-scanning camera system with 11 infrared sensors. Step length, width and height, maximum circumduction with the right and left leg, maximum knee flexion angle of the right and left leg, and trunk sway were measured and compared using paired t-tests (α = 0.005). In addition, variability in these parameters during one-minute intervals was examined. The fatigue index was defined as the number of significant mean and SD changes from the beginning to the end of the exertion test relative to the total number of gait kinematic parameters.

Results

Clearly, for some patients the mean gait parameters were more affected than the variability of their movements while other patients had smaller differences in mean gait parameters with greater increases in variability. Finally, for other patients gait changes with physical exertion manifested both in changes in mean gait parameters and in altered variability. The variability and fatigue indices correlated significantly with the motoric but not with the cognitive dimension of the FSMC score (R = -0.602 and R = -0.592, respectively; P < 0.026).

Conclusions

Changes in gait patterns following a physical exertion test in patients with MS suffering from motor fatigue can be measured objectively. These changes in gait patterns can be described using the motor fatigue index and represent an objective measure to assess motor fatigue in MS patients. The results of this study have important implications for the assessments and treatment evaluations of fatigue in MS.

Symptomatic therapy in multiple sclerosis

Multiple sclerosis is the most common disabling neurological disease of young adults. The ability to impact the quality of life of patients with multiple sclerosis should not only incorporate therapies that are disease modifying, but should also include a course of action for the global multidisciplinary management focused on quality of life and functional capabilities.

Pharmacological interventions for spinal cord injury: where do we stand? How might we step forward?

Despite numerous studies reporting some measures of efficacy in the animal literature, there are currently no effective therapies for the treatment of traumatic spinal cord injuries (SCI) in humans. The purpose of this review is to delineate key pathophysiological processes that contribute to neurological deficits after SCI, as well as to describe examples of pharmacological approaches that are currently being tested in clinical trials, or nearing clinical translation, for the therapeutic management of SCI. In particular, we will describe the mechanistic rationale to promote neuroprotection and/or functional recovery based on theoretical, yet targeted pathological events. Finally, we will consider the clinical relevancy for emerging evidence that pharmacologically targeting mitochondrial dysfunction following injury may hold the greatest potential for increasing tissue sparing and, consequently, the extent of functional recovery following traumatic SCI.

Plasma carnitine is associated with fatigue in chronic hepatitis C but not in the irritable bowel syndrome

BACKGROUND

Fatigue is an important determinant of altered quality of life in patients affected by chronic hepatitis C or the irritable bowel syndrome (IBS).

AIM

In this study, we aimed at determining the contributory role of plasma levels of leptin and carnitine on fatigue in chronic hepatitis C and IBS.

METHODS

We enrolled 81 patients with chronic hepatitis C, 42 with IBS and 44 healthy subjects. Fatigue was evaluated using the Fatigue Impact Scale questionnaire. Body composition was assessed through impedance analysis. Plasma carnitine and leptin were measured.

RESULTS

Fatigue scores were significantly more elevated in patients with chronic hepatitis C and IBS than in healthy subjects. Patients with chronic hepatitis C but not IBS, had significant lower plasma levels of total and free carnitine adjusted for fat mass compared with healthy subjects. In patients with chronic hepatitis C and not with IBS, fatigue scores were negatively correlated with plasma levels of carnitine. Levels of free carnitine were significantly and independently associated with the severity of fatigue in patients with chronic hepatitis C [OR=2.019, P=0.02, CI 95% (1.01-1.23)].

CONCLUSIONS

In patients with chronic hepatitis C, the severity of fatigue is associated with a low level of carnitine, suggesting that an oral supplementation may be effective to relieve fatigue in chronic hepatitis C. The underlying mechanism of fatigue in IBS does not seem to involve carnitine.

Open, uncontrolled, nonrandomized, 9-month, off-label use of bupropion to treat fatigue in a single patient with multiple sclerosis

BACKGROUND

Improvement of fatigue in patients with multiple sclerosis (MS) who were given bupropion has been previously reported, but scales for lethargy and depression were not used.

OBJECTIVE

This letter describes the course of chronic fatigue in a patient with MS who received off-label treatment with bupropion.

METHODS

A 47-year-old white woman (weight, 56 kg) with a 7-year history of relapsing-remitting MS (Ex- panded Disability Status Scale score of 3), without previous use of medication for MS, presented with a complaint of irritability and chronic fatigue. The Fatigue Severity Scale (FSS) documented the presence of fatigue related to MS (score of 7). The Beck Depression Inventory scale excluded an association between depression and fatigue (score of 8; possible range, 0-24); both the Pittsburgh Sleep Quality Index (score of 4; possible range, 0-21) and the Epworth Sleepiness Scale (score of 6; possible range, 0-24) excluded nighttime and daytime sleep disturbances. The patient was started on amantadine (100 mg/d), with an increase to 100 mg every 12 hours 2 weeks later, for the persistence of fatigue. Three months later, the absence of clinical response was noted (FSS score of 7). Amantadine was discontinued and bupropion therapy was initiated at 300 mg/d.

RESULTS

A repeat clinical evaluation conducted after 3 months of bupropion treatment indicated an improvement in fatigue (FSS score of 4) without changes in Beck Depression Inventory, Pittsburgh Sleep Quality Index, or Epworth Sleepiness Scale scores. The discontinuation and reinitiation of bupropion confirmed the effectiveness of bupropion for improving chronic fatigue in this patient. At the time of writing this report, 13 months after the resumption of bupropion treatment, the patient had experienced no further episodes of fatigue, and no adverse events had been reported.

CONCLUSION

This patient with relapsing-remitting MS experienced improvements in chronic fatigue (as measured by FSS) after treatment with bupropion, but properly designed, randomized, active- and placebo-controlled clinical trials are needed to evaluate the efficacy and safety of bupropion in more patients with MS and fatigue.

Health-related quality of life in relapsing remitting multiple sclerosis patients during treatment with glatiramer acetate: a prospective, observational, international, multi-centre study

Background

Glatiramer acetate (GA) and interferon-beta (INFb) are first-line disease modifying drugs for relapsing remitting multiple sclerosis (RRMS). Treatment with INFb is associated with a significant increase in health-related quality of life (HR-QoL) in the first 12 months. It is not known whether HR-QoL increases during treatment with GA.

Methods

197 RRMS patients, 106 without and 91 with prior immunomodulation/immunosuppression, were studied for HR-QoL (Leeds Multiple Sclerosis-QoL [LMS-QoL] scale, score range 0 - 32), fatigue (Fatigue Impact Scale [FIS]) and depressed mood (Beck Depression Inventory-Short Form [BDI-SF]) at baseline and 6 and 12 months after start of GA treatment.

Results

At 6 and 12 months mean LMS-QoL scores were significantly increased in the treatment-naive patient group (p < 0.001), not in the pre-treated group. At month 12 43% of treatment-naïve patients had improved HR-QoL (increase LMS-QoL score 3 or more points) (p < 0.001). Likewise, mean FIS scores were decreased at months 6 and 12 in the treatment-naïve group (p < 0.01), not in the pre-treated group. In both groups mean BDI-SF scores did not change. No demographic or clinical baseline factor was predictive of HR-QoL increase. HR-QoL changes were zero to negative for patients who had discontinued GA before month 12 (28.4% of patients).

Conclusions

In RRMS patients without prior immunomodulation/immunosuppression treatment with GA was associated with an increase in HR-QoL in the first 6 months, that was sustained at 12 months. In 4 out of 10 patients HR-QoL improved. Increase in HR-QoL was associated with decrease in fatigue.

Pharmacological treatments for fatigue associated with palliative care

BACKGROUND

In healthy individuals, fatigue is a protective response to physical or mental stress, often relieved by rest. By contrast, in palliative care patients fatigue can be severely debilitating, thereby impacting daily activity and quality of life, often with rest not counteracting fatigue. Fatigue frequently occurs in patients with advanced disease and modalities treating cancer often contribute or cause fatigue. Further complicating issues are its multidimensionality, subjective nature, and lack of a consensus definition of fatigue. Pathophysiology is not fully understood and evidence-based treatment approaches are needed.

OBJECTIVES

The objective was to determine efficacy of pharmacological treatments on non-specific fatigue in palliative care. The focus was on patients at an advanced stage of disease, including cancer and other chronic diseases associated with fatigue, aiming to relieve fatigue. Studies aiming at curative treatment (e.g. surgical intervention for early breast cancer) were not included.

SEARCH STRATEGY

We searched EMBASE; Psych Lit, CENTRAL and MEDLINE to June 2009.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) concerning adult palliative care with focus on pharmacological treatment of fatigue. The primary outcome had to be non-specific fatigue (or related terms such as asthenia).

DATA COLLECTION AND ANALYSIS

Results were screened and included if they met the selection criteria. If two or more studies were identified that investigated a specific drug in a population with the same disease, meta-analysis was conducted. In addition, comparison of type of drug investigated in a specific population as well as comparison of frequent adverse effects of fatigue treatment was done by creating overview tables.

MAIN RESULTS

More than 2000 publications were screened, and 22 met inclusion criteria. In total, data from 11 drugs and 1632 participants were analysed. Studies investigating amantadine, pemoline, and modafinil in participants with Multiple Sclerosis (MS)-associated fatigue and methylphenidate in patients suffering from advanced cancer and fatigue could be used for meta-analysis. Amantadine in MS and methylphenidate in cancer patients showed a superior effect. Most studies had low participant numbers and were heterogenous.

AUTHORS' CONCLUSIONS

Based on limited evidence, we cannot recommend a specific drug for treatment of fatigue in palliative care patients. Surprisingly, corticosteroids have not been a research focus for fatigue treatment, although these drugs are frequently used. Recent fatigue research seems to focus on modafinil, which may be beneficial although there is no evidence currently. Amantadine and methylphenidate should be further examined. Consensus regarding fatigue assessment in advanced disease is needed.

Metabolomic profiles indicate distinct physiological pathways affected by two loci with major divergent effect on Bos taurus growth and lipid deposition

Identifying trait-associated genetic variation offers new prospects to reveal novel physiological pathways modulating complex traits. Taking advantage of a unique animal model, we identified the I442M mutation in the non-SMC condensin I complex, subunit G ( NCAPG) gene and the Q204X mutation in the growth differentiation factor 8 ( GDF8) gene as substantial modulators of pre- and/or postnatal growth in cattle. In a combined metabolomic and genotype association approach, which is the first respective study in livestock, we surveyed the specific physiological background of the effects of both loci on body-mass gain and lipid deposition. Our data provided confirming evidence from two historically and geographically distant cattle populations that the onset of puberty is the key interval of divergent growth. The locus-specific metabolic patterns obtained from monitoring 201 plasma metabolites at puberty mirror the particular NCAPG I442M and GDF8 Q204X effects and represent biosignatures of divergent physiological pathways potentially modulating effects on proportional and disproportional growth, respectively. While the NCAPG I442M mutation affected the arginine metabolism, the 204X allele in the GDF8 gene predominantly raised the carnitine level and had concordant effects on glycerophosphatidylcholines and sphingomyelins. Our study provides a conclusive link between the well-described growth-regulating functions of arginine metabolism and the previously unknown specific physiological role of the NCAPG protein in mammalian metabolism. Owing to the confirmed effect of the NCAPG/LCORL locus on human height in genome-wide association studies, the results obtained for bovine NCAPG might add valuable, comparative information on the physiological background of genetically determined divergent mammalian growth.

Central and peripheral fatigue: exemplified by multiple sclerosis and myasthenia gravis

Fatigue is a feature of several chronic diseases of the central and peripheral nervous system. The pathophysiology of central fatigue is complex and often not well-defined. In contrast, peripheral fatigue is more objectively defined and measured. Fatigue can be part of the primary disease process, but there are often contributions from comorbid factors such as depression, sleep disturbance, medication, or deconditioning. Multiple sclerosis (MS) offers an example of central fatigue. More than 40% of MS patients complain of fatigue. Validated questionnaires are used to assess fatigue severity and comorbid factors. Although fatigue is believed to be a primary process in MS, depression and sleep disturbance are often comorbid problems. Magnetic resonance imaging (MRI), positron emission tomography, and functional MRI studies suggest that fatigue is related to gray matter disease, particularly of the cerebral cortex, but also of the thalamus and caudate. Disruption of impulse propagation from demyelination is also a likely factor. It is uncertain if pro-inflammatory cytokines have a specific effect on the genesis of MS fatigue. Several medications have been reported to alleviate fatigue in MS, but controlled studies show contradictory results. Treatment of depression and sleep disturbance, use of exercise programs and rehabilitation therapies as well as treatment of other comorbid conditions is necessary for optimal alleviation of fatigue. Myasthenia gravis (MG) patients exhibit peripheral fatigue. In contrast to MS, the mechanism of weakness and fatigue in MG is well-defined. Antibodies to the postsynaptic acetylcholine receptor at the myoneural junction cause diminution of the force of muscle contractions. This leads to a feeling of fatigue. MG treatments increase the availability of acetylcholine and reduce antibody formation. Evaluation for comorbid conditions, especially thymoma and hyperthyroidism, are mandatory in patients with MG.

Correlation between fatigue and self-esteem in patients with multiple sclerosis

OBJECTIVE

To assess the possible association of fatigue with self-esteem in multiple sclerosis (MS) patients.

METHOD

Thirty patients were prospectively assessed. None of them presented moderate or severe depression or anxiety and their degree of disability was low (EDSS<or=3.5). They had been clinically stable for at least three months and had been receiving the same medication for at least six months. Socioeconomic level was assessed. Severity of fatigue and self-esteem were evaluated using specific, validated scales. Patients with moderate to severe anxiety and/or depression were excluded.

RESULTS

Low self-esteem correlated with fatigue (p=0.01), but not with any other variables, such as age, gender, EDSS, MS duration, number of relapses, mild depression and/or anxiety.

CONCLUSION

Greater severity of fatigue in MS correlates with low self-esteem, thus suggesting that this chronic complaint that affects so many patients can interfere with the way in which they see and value themselves.

Acetyl-L-carnitine ameliorates mitochondrial dysfunction following contusion spinal cord injury

In the present study, we evaluated the therapeutic efficacy of acetyl-l-carnitine (ALC) administration on mitochondrial dysfunction following tenth thoracic level contusion spinal cord injury (SCI) in rats. Initial results from experiments in vitro with naïve mitochondria showed that, in the absence of pyruvate, ALC can be used as an alternative substrate for mitochondrial respiration. Additionally, when added in vitro to mitochondria isolated from 24 h injured cords, ALC restored respiration rates to normal levels. For administration studies in vivo, injured rats were given i.p. injections of saline (vehicle) or ALC (300 mg/kg) at 15, 30 or 60 min post-injury, followed by one booster after 6 h. Mitochondria were isolated 24 h post-injury and assessed for respiration rates, activities of NADH dehydrogenase, cytochrome c oxidase and pyruvate dehydrogenase. SCI significantly (p < 0.05) decreased respiration rates and activities of all enzyme complexes, but ALC treatment significantly (p < 0.05) maintained mitochondrial respiration and enzyme activities compared with vehicle treatment. Critically, ALC administration in vivo at 15 min and 6 h post-injury versus vehicle, followed once daily for 7 days, significantly (p < 0.05) spared gray matter. In summary, ALC treatment maintains mitochondrial bioenergetics following contusion SCI and, thus, holds great potential as a neuroprotective therapy for acute SCI.

Carnitine for fatigue in multiple sclerosis

BACKGROUND

Fatigue is reported to occur in up to 92% of patients with multiple sclerosis (MS) and has been described as the most debilitating of all MS symptoms by 28% to 40% of MS patients.

OBJECTIVES

To assess whether carnitine (enteral or intravenous) supplementation can improve the quality of life and reduce the symptoms of fatigue in patients with MS-related fatigue and to identify any adverse effects of carnitine when used for this purpose.

SEARCH STRATEGY

A literature search was performed using Cochrane MS Group Trials Register (21 May 2009), Cochrane Central Register of Controlled Trials (CENTRAL) "The Cochrane Library 2009, issue 2, MEDLINE (PubMed) (1966-21 May 2009), EMBASE (1974-21 May 2009). Reference lists of review articles and primary studies were also screened. A hand search of the abstract book of recent relevant conference symposia was also conducted. Personal contact with MS experts and a manufacturer (Source Naturals, United States) of carnitine formulation was contacted to determine if they knew of other clinical trials. No language restrictions were applied.

SELECTION CRITERIA

Full reports of published and unpublished randomized controlled trials and quasi-randomized trials of any carnitine intervention in adults with a clinical diagnosis of fatigue associated with multiple sclerosis were included.

DATA COLLECTION AND ANALYSIS

Data from the eligible trials was extracted and coded using a standardized data extraction form and entered into RevMan 5. Discrepancies were to be resolved by discussion with a third reviewer however this was not necessary. The quality items to be assessed were method of randomization, allocation concealment, blinding (participants, investigators, outcome assessors and data analysis), intention-to-treat analysis and completeness of follow up.

MAIN RESULTS

The search identified one randomized cross-over trial. In this study patients were exposed to both acetyl L-carnitine (ALCAR(tm)) 2 grams daily and amantadine 200 mg daily in adult patients with relapsing-remitting and secondary progressive MS. The effects of carnitine on fatigue are not clear based on the one included crossover RCT. There was no difference between carnitine and amantadine for the number of patients withdrawing from the study due to an adverse event (relative risk ratio 0.20; 95% confidence interval 0.03 to 1.55. Mortality, serious adverse events, total adverse events, and quality of life were not reported.

AUTHORS' CONCLUSIONS

There is insufficient evidence that carnitine for the treatment of MS-related fatigue offers a therapeutic advantage over placebo or active comparators.

Fatigue in multiple sclerosis: mechanisms and management

Multiple sclerosis [MS] is a chronic immune-mediated disorder of the central nervous system [CNS]. Fatigue may be a debilitating symptom in MS patients, adversely impacting on their quality of life. Clinically, fatigue may manifest as exhaustion, lack of energy, increased somnolence, or worsening of MS symptoms. Activity and heat typically serve to exacerbate symptoms of fatigue. There is now strong evidence to suggest that fatigue results from reduced voluntary activation of muscles by means of central mechanisms. Given that axonal demyelination is a pathological hallmark of MS, activity-dependent conduction block [ADCB] has been proposed as a mechanism underlying fatigue in MS. This ADCB results from axonal membrane hyperpolarization, mediated by the Na(+)/K(+) electrogenic pump, with conduction failure precipitated in demyelinated axons with a reduced safety factor of impulse transmission. In addition, Na(+)/K(+) pump dysfunction, as reported in MS, may induce a depolarizing conduction block associated with inactivation of Na(+) channels. These processes may induce secondary effects including axonal degeneration triggered by raised levels of intracellular Ca(2+) through reverse operation of the Na(+)-Ca(2+) exchanger. Restoration of normal conduction in demyelinated axons with selective channel blockers improves fatigue and may yet prove useful as a neuroprotective strategy, in preventing secondary axonal degeneration and consequent functional impairment.

Fatigue in multiple sclerosis

In summary, MS-related fatigue can be a severe problem causing interference with home and vocational activities. There are multiple factors that can contribute to fatigue in MS, and it is important for the patient, family, and clinician to be aware of potential confounders that may worsen fatigue. Clearer understanding about the etiology of fatigue is necessary. Additional larger, randomized, clinical trials are needed to evaluate etiology, pathophysiology, and both pharmacologic and nonpharmacologic interventions. Given the varying nature of fatigue and the limited evidence that fatigue in MS patients is highly dependent on self-perceived scores, additional research into the effect of psychosocial and psychological interventions is recommended. A multidisciplinary approach to fatigue is encouraged when treatments are considered for maximum benefit.

Acetyl l-carnitine (ALC) treatment in elderly patients with fatigue

Fatigue is one of the conditions most frequently complained by the elderly. There are few effective treatment options for patients with chronic fatigue syndrome. To determine the efficacy, tolerability and impact on the fatigue, as well as on cognitive and functional status of elderly subjects with acetyl L-carnitine (ALC), 96 aged subjects (>70 years, range 71-88) were investigated (50 females and 46 males; mean age 76.2+/-7.6 and 78.4+/-6.4 years, respectively). They met four or more of the Holmes major criteria or at least six of Fukuda minor criteria. Fatigue was measured with the Wessely and Powell [Wessely, S., Powell, R., 1989. Fatigue syndromes: a comparison of chronic postviral fatigue with neuromuscular and affective disorders. J. Neurol. Neurosurg. Psychiatry 52, 940-948] scores, with the fatigue severity scale. At the end of the treatment, we observed a decrease of physical fatigue: 6.2 (p<0.001), of mental fatigue: 2.8 (p<0.001), of severity fatigue: 21.0 (p<0.001) and improvements in functional status: 16.1 (p<0.001) and cognitive functions: 2.7 (p<0.001). By the end of the treatment, significant differences between the two groups were found for the following parameters: muscle pain -27% versus -3% (p<0.05); prolonged fatigue after exercise: 51% versus -4% (p<0.0001); sleep disorders: 28% versus 4% (p<0.05); physical fatigue: 7 versus -0.5 (p<0.0001); mental fatigue: -3.3 versus 0.6 (p<0.0001); fatigue severity scale: -22.5 versus 1.2 (p<0.0001); functional status 17.1 versus 0.6 (p<0.0001); mini mental state examination (MMSE) improvements: 3.4 versus 0.5 (p<0.0001). Our data show that administering ALC may reduce both physical and mental fatigue in elderly and improves both the cognitive status and physical functions.

A randomized controlled trial of cognitive behavior therapy for multiple sclerosis fatigue

BACKGROUND

The purpose of this study was to assess the efficacy of cognitive behavior therapy (CBT) as a treatment for multiple sclerosis (MS) fatigue.

METHODS

A randomized controlled design was used where 72 patients with MS fatigue were randomly assigned to eight weekly sessions of CBT or relaxation training (RT). RT was designed to control for therapist time and attention. Participants were assessed before and after treatment, and at 3 and 6 months posttreatment. The primary outcome was the Fatigue Scale. Secondary outcomes included measures of stress, mood, and fatigue-related impairment.

RESULTS

Analysis was by intention-to-treat. A group by time interaction showed that the CBT group reported significantly greater reductions in fatigue across the 8 months compared with the RT group (p < .02). Calculated effect sizes for fatigue from baseline to the end of treatment were 3.03 [95% confidence interval, 2.22-3.68] for the CBT group and 1.83 [95% confidence interval, 1.26-2.34] for the RT group. Results also indicted that both groups showed clinically significant decreases in fatigue defined as fatigue levels equivalent or less than those reported by a non-fatigued healthy comparison group. There were no significant interactions between group and any of the secondary outcome variables, with both groups showing improvements over time on all measures.

INTERPRETATION

Both CBT and RT appear to be clinically effective treatments for fatigue in MS patients, although the effects for CBT are greater than those for RT. Even 6 months after treatment, both treatment groups reported levels of fatigue equivalent to those of the healthy comparison group.

A longitudinal study on effects of a six-week course for energy conservation for multiple sclerosis patients

Objective Fatigue management and energy conservation are effective strategies to minimize fatigue in multiple sclerosis (MS). Sustained results have not yet been reported.

Methods A fatigue management course was provided for 32 MS patients. They were tested prior to, directly after participation in the course and in a 7—9 month follow-up with the Fatigue Severity Scale, the MS-specific Fatigue Scale, the Modified Fatigue Impact Scale (MFIS), the Pittsburgh Sleep Quality Index and a self-rating scale for depression. The Expanded Disability Status Score (EDSS) and the MS functional composite (MSFC) were evaluated before and after participation in the course.

Results The total score and the Cognitive and Physical subscores of the MFIS showed significant improvements on both points of time. Scores in the Fatigue Severity Scale, MS-specific Fatigue Scale and Psychosocial Fatigue Impact Scale did not improve significantly. MS functional composite and EDSS remained unchanged after six weeks of course participation. Subjective sleep quality improved directly after participation in the course and after 7—9 months. The depression score decreased significantly to a normal level at the end of training and in the 7—9 month follow-up.

Conclusion Fatigue management enables MS patients to cope with their fatigue and energy more effectively. Follow-up evaluations showed stable results after 7—9 months. Multiple Sclerosis 2008; 14: 500—505. http://msj.sagepub.com

Possible mechanisms of the formation of chronic fatigue syndrome in the clinical picture of multiple sclerosis

A frequent manifestation of multiple sclerosis (MS) is chronic fatigue syndrome, which can be defined as a subjective decrease in the level of physical and/or mental energy. Chronic fatigue syndrome can be divided into asthenia (fatigue at rest), pathological fatigability (fatigue on physical loading), and fatigue on the background of deterioration of other symptoms (exacerbation of MS). There are both central and peripheral mechanisms for the formation of fatigue. The combination of fatigue and affective disturbances, especially depression and sleep disorders (insomnia, restless legs syndrome) is common in MS and may provide evidence that they share common mechanisms--decreases in the activity of the serotoninergic and noradrenergic systems. An important component in the formation of chronic fatigue syndrome consists of endocrine and autoimmune factors, the latter having a greater effect on asthenia than on pathological fatigue. Further studies of the pathogenetic mechanisms of the formation of asthenia and pathological fatigue and clarification of their differential diagnostic signs should allow not only a better understanding of the nature of this syndrome, but also better selection of individual treatment.

L-Carnitine in the treatment of fatigue in adult celiac disease patients: a pilot study

BACKGROUND

Fatigue is common in celiac disease. L-Carnitine blood levels are low in untreated celiac disease. L-Carnitine therapy was shown to improve muscular fatigue in several diseases.

AIM

To evaluate the effect of L-carnitine treatment in fatigue in adult celiac patients.

METHODS

Randomised double-blind versus placebo parallel study. Thirty celiac disease patients received 2 g daily, 180 days (L-carnitine group) and 30 were assigned to the placebo group (P group). The patients underwent clinical investigation and questionnaires (Scott-Huskisson Visual Analogue Scale for Asthenia, Verbal Scale for Asthenia, Zung Depression Scale, SF-36 Health Status Survey, EuroQoL). OCTN2 levels, the specific carnitine transporter, were detected in intestinal tissue.

RESULTS

Fatigue measured by Scott-Huskisson Visual Analogue Scale for Asthenia was significantly reduced in the L-carnitine group compared with the placebo group (p=0.0021). OCTN2 was decreased in celiac patients when compared to normal subjects (-134.67% in jejunum), and increased after diet in both celiac disease treatments. The other scales used did not show any significant difference between the two celiac disease treatment groups.

CONCLUSION

L-Carnitine therapy is safe and effective in ameliorating fatigue in celiac disease. Since L-carnitine is involved in muscle energy production its decreased absorption due to OCTN2 reduction might explain muscular symptoms in celiac disease patients. The diet-induced OCTN2 increase, improving carnitine absorption, might explain the L-carnitine treatment efficacy.

Amantadine treatment of hemispatial neglect: a double-blind, placebo-controlled study

OBJECTIVE

The resemblance of some aspects of the hemispatial neglect syndrome (hypokinesia, decreased arousal) to aspects of Parkinsonian syndromes, and the success of amantadine in treating disorders of attention, prompted a placebo-controlled, double-blind trial of amantadine, an inhibitor of the N-methyl D-aspartate (NMDA) glutamate receptor that modulates dopamine transmission, in four patients with chronic hemispatial neglect.

DESIGN

Patients received placebo or 100 mg of amantadine twice a day in an ABA design. Dependent measures of drug effect included an extensive battery of tests assessing arousal, hemiinattention, hemihypokinesia, personal neglect, disability, anosognosia, family burden, and naturalistic action.

RESULTS

There was no evidence of increased adverse effects with the treatment drug compared with placebo. Of the 17 measures used to assess treatment response in the four patients (68 measures total), linear regressions revealed significant positive treatment effects on very few (four) measures (uncorrected for multiple comparisons), and scattered negative responses to treatment were evident on three measures. The vast majority of measures showed no change in response to treatment.

CONCLUSIONS

Possible reasons for failure of treatment effects in the present study are discussed. Additional study will be required to determine whether there are neglect patients who may benefit from amantadine.

Amantadine for fatigue in multiple sclerosis

BACKGROUND

Fatigue is one of the most common and disabling symptoms of people with Multiple Sclerosis (MS). The effective management of fatigue has an important impact on the patient's functioning, abilities, and quality of life. Although a number of strategies have been devised for reducing fatigue, treatment recommendations are based on a limited amount of scientific evidence. Many textbooks report amantadine as a first-choice drug for MS-related fatigue because of published randomised controlled trials (RCTs) showing some benefit.

OBJECTIVES

To determine the effectiveness and safety of amantadine in treating fatigue in people with MS.

SEARCH STRATEGY

We searched The Cochrane MS Group Trials Register (July 2006), The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2006), MEDLINE (January 1966 to July 2006), EMBASE (January 1974 to July 2006), bibliographies of relevant articles and handsearched relevant journals. We also contacted drug companies and researchers in the field.

SELECTION CRITERIA

Randomised, placebo or other drugs-controlled, double-blind trials of amantadine in MS people with fatigue.

DATA COLLECTION AND ANALYSIS

Three reviewers selected studies for inclusion in the review and they extracted the data reported in the original articles. We requested missing and unclear data by correspondence with the trial's principal investigator. A meta-analysis was not performed due to the inadequacy of available data and heterogeneity of outcome measures.

MAIN RESULTS

Out of 13 pertinent publications, 5 trials met the criteria for inclusion in this review: one study was a parallel arms study, and 4 were crossover trials. The number of randomised participants ranged between 10 and 115, and a total of 272 MS patients were studied. Overall the quality of the studies considered was poor and all trials were open to bias. All studies reported small and inconsistent improvements in fatigue, whereas the clinical relevance of these findings and the impact on patient's functioning and health related quality of life remained undetermined. The number of participants reporting side effects during amantadine therapy ranged from 10% to 57%.

AUTHORS' CONCLUSIONS

The efficacy of amantadine in reducing fatigue in people with MS is poorly documented, as well as its tolerability. It is advisable to: (1) improve knowledge on the underlying mechanisms of MS-related fatigue; (2) achieve anagreement on accurate, reliable and responsive outcome measures of fatigue; (3) perform good quality RCTs.

Effectiveness of non-pharmacological interventions for fatigue in adults with multiple sclerosis, rheumatoid arthritis, or systemic lupus erythematosus: a systematic review

AIM

This paper reports a systematic review of non-pharmacological interventions for fatigue in adults with three common autoimmune conditions.

BACKGROUND

A considerable proportion of people with multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus experience compromised quality of life due to fatigue. Recent reviews of pharmacotherapies for fatigue in these conditions remain inconclusive, and systematic evidence for effectiveness of non-pharmacological interventions was unavailable. Our paper addresses this gap.

METHODS

The literature search used the key words fatigue, energy, multiple sclerosis, rheumatoid arthritis and systemic lupus. It included 19 electronic databases and libraries, three evidence-based journals, two internet search engines, was dated 1987-2006, and limited to English. Non-pharmacological experimental studies about fatigue comprising more than five adults were included. Meta-analysis was not possible due to diverse interventions and outcome measures, therefore studies were analysed by types of interventions used to reduce fatigue.

RESULTS

Of 653 hits, 162 papers were reviewed, and 36 met the inclusion criteria. Thirty-three primary studies reported 14 randomized controlled trials and 19 quasi-experimental designs. Most interventions were tested with people with multiple sclerosis. Exercise, behavioural, nutritional and physiological interventions were associated with statistically significant reductions in fatigue. Aerobic exercise was effective, appropriate and feasible for reducing fatigue among adults with chronic autoimmune conditions. Electromagnetic field devices showed promise. The diversity of interventions, designs, and using 24 different instruments to measure fatigue, limited comparisons.

CONCLUSION

Low impact aerobic exercise gradually increasing in intensity, duration and frequency may be an effective strategy in reducing fatigue in some adults with chronic auto-immune conditions. However, fatigue is a variable and personal experience and a range of behavioural interventions may be required. Well-designed studies testing these promising strategies and consensus on outcome fatigue measures are needed.

Risk assessment for carnitine

Carnitine is a conditionally essential amino acid-like compound involved in the transport of long-chain fatty acids into the mitochondria during the beta-oxidation process. Carnitine has become an increasingly popular ingredient in dietary supplements, especially weight loss and some sports nutrition products. A number of clinical trials have been conducted examining the effect of carnitine supplementation on weight loss and energy balance. Regarding safety, systematic evaluation of the research designs and data do not provide a basis for risk assessment and the usual safe upper level of intake (UL) derived from it unless the newer methods described as the observed safe level (OSL) or highest observed intake (HOI) are utilized. The OSL risk assessment method indicates that the evidence of safety is strong at intakes up to 2000mg/day l-carnitine equivalents for chronic supplementation, and this level is identified as the OSL. Although much higher levels have been tested without adverse effects and may be safe, the data for intakes above 2000mg/day are not sufficient for a confident conclusion of long-term safety.

Symptomatic treatment of multiple sclerosis. Multiple Sclerosis Therapy Consensus Group (MSTCG) of the German Multiple Sclerosis Society

Besides immunomodulation and immunosuppression, the specific treatment of symptoms is an essential component of the overall management of multiple sclerosis (MS). Symptomatic treatment is aimed at the elimination or reduction of symptoms impairing the functional abilities and quality of life of the affected patients. Moreover, with symptomatic treatment the development of a secondary physical impairment due to an existing one may be avoided. Many therapeutic techniques as well as different drugs are used for the treatment of MS symptoms, but only a few of them have been investigated, especially in MS patients, and are approved by the national health authorities. Despite an overwhelming number of publications, only a few evidence-based studies exist and consensus reports are very rare, too. Therefore, it seemed necessary to develop a consensus statement on symptomatic treatment of MS comprising existing evidence-based literature as well as therapeutic experience of neurologists who have dealt with these problems over a long time. This consensus paper contains proposals for the treatment of the most common MS symptoms: disorders of motor function and coordination, of cranial nerve function, of autonomic, cognitive, and psychological functions as well as MS-related pain syndromes and epileptic seizures.

Acetyl-L-carnitine up-regulates expression of voltage-dependent anion channel in the rat brain

Acetyl-L-carnitine (ALC) exerts unique neuroprotective, neuromodulatory, and neurotrophic properties, which play an important role in counteracting various pathological processes, and have antioxidative properties, protecting cells against lipid peroxidation. In this study, suppression subtractive hybridization (SSH) method was applied for the generation of subtracted cDNA libraries and the subsequent identification of differentially expressed transcripts after treatment of rats with ALC. The technique generates an equalized representation of differentially expressed genes irrespective of their relative abundance and it is based on the construction of forward and reverse cDNA libraries that allow the identification of the genes that are regulated after ALC treatment. In the present paper, we report the identification of the gene of mitochondrial voltage-dependent anion channel (VDAC) protein which is positively modulated by the ALC treatment. VDAC is a small pore-forming protein of the mitochondrial outer membrane. It represents an interesting tool for Ca(2+) homeostasis, and it plays a central role in apoptosis. In addition, VDAC seems to have a relevant role in the synaptic plasticity.