Nature of fatigue moderates depressive symptoms and anxiety in sarcoidosis

Obstructive Sleep Apnea and Sarcoidosis Interactions

Obstructive sleep apnea (OSA) is very prevalent in sarcoidosis patients. Sarcoidosis of the upper respiratory tract may affect upper airway patency and increase the risk of OSA. Weight gain due to steroid use, upper airway myopathy due to steroids and sarcoidosis itself, and interstitial lung disease with decreased upper airway patency are other reasons for the higher OSA prevalence seen in sarcoidosis. Several clinical manifestations such as fatigue, hypersomnolence, cognitive deficits, and pulmonary hypertension are common to both OSA and sarcoidosis. Therefore, early screening and treatment for OSA can improve symptoms and overall patient quality of life.

Quality of life in sarcoidosis

Having sarcoidosis often has a major impact on quality of life of patients and their families. Improving quality of life is prioritized as most important treatment aim by many patients with sarcoidosis, but current evidence and treatment options are limited. In this narrative review, we describe the impact of sarcoidosis on various aspects of daily life, evaluate determinants of health-related quality of life (HRQoL), and provide an overview of the different patient-reported outcome measures to assess HRQoL in sarcoidosis. Moreover, we review the current evidence for pharmacological and non-pharmacological interventions to improve quality of life for people with sarcoidosis.

Perceptions of the Fatigue Experience and a Breathing Awareness Meditation-Integrated mHealth App for Fatigue and Stress in Patients with Sarcoidosis

Objective

Sarcoidosis-associated fatigue is a debilitating consequence of sarcoidosis, a multi-system inflammatory disease, and may be related to increased stress associated with sarcoidosis. Breathing awareness meditation has potential as an intervention for managing stress and fatigue for sarcoidosis patients (SPs). This project's aim was to obtain feedback from key informants to design and tailor a patient-centered Sarcoidosis Patient Resource and Companion (SPARC) mHealth App developed for SPs to manage fatigue and stress at home using breathing awareness meditation.

Methods

We used a mixed-method patient/user-centered design with triangulation to understand SPs experiences of sarcoidosis-associated fatigue and stress (n = 13), and obtain feedback on the SPARC App-prototype integrating breathing awareness meditation from these SPs and health care team members (HCTMs; n = 5). Using deductive content analysis, transcribed interviews were coded for themes and subthemes.

Results

We report on findings from qualitative interviews and assessment of SPs' experiences including themes describing fatigue/stress interactions. Themes indicated that SPs find fatigue to be a profoundly difficult experience affecting multiple domains of functioning for which they perceive few effective strategies to cope. SPs and HCTMs shared feedback on the SPARC App-prototype after a test session; it was reported to be user friendly and to have potential for improving fatigue/stress, and key points for tailoring the App to SPs were shared.

Conclusion

Sarcoidosis-associated fatigue poses a significant burden for SPs. The SPARC App-prototype with breathing awareness meditation was acceptable and feasible to use and was well-received by SPs and HCTMs. Future iterations of the SPARC App to test the effect of breathing awareness meditation on fatigue will need to incorporate recommendations for tailoring for SPs.

The clinical correlations of fatigue in patients with sarcoidosis

Introduction: Fatigue is considered a frequent and characteristic feature of sarcoidosis. This study was designed to determine the prevalence of fatigue in patients with sarcoidosis and to determine its potential clinical correlations in relation to symptom severity. Methods: A total of 56 sarcoidosis patients were included. Data on patient demographics, anthropometrics, disease characteristics, pulmonary function tests, 6-min walking distance (6MWD), blood biochemistry and hemogram findings were retrieved from hospital records. Psychometric instruments involved fatigue assessment scale (FAS), Beck Depression Inventory (BDI) and Short Form-36 (SF-36) for health-related QOL (HRQOL). Results: Mean±SD patient age was 50.9±11.9 years. Of 56 patients, 44 were females and 12 were males. When compared to FAS score

A prospective, one-year follow-up study of patients newly diagnosed with neurosarcoidosis

METHODS

Twenty patients with newly diagnosed neurosarcoidosis were examined for multiple outcomes in an observational cohort study with 12-month follow-up.

RESULTS

The patients' contrast-enhancing lesions on MRI scans reduced during treatment (p < 0.0001). The mean modified Rankin Score improved from 3.0 to 1.8 (p < 0.0001), and 75% of patients experienced clinically important improvement. Patients improved on the Symbol Digit Modalities Test (p < 0.0001) and on SF-36 Physical (p = 0.003) and Mental Component Summary scores (p = 0.03). Proportions of patients with substantial fatigue (75%) and high depression score (35%) were unchanged.

CONCLUSIONS

12-month immunosuppression improved several outcomes, and 75% of patients experienced clinically important improvement.

Perceptions of fatigue in patients with idiopathic pulmonary fibrosis or sarcoidosis

Background

Fatigue is highly prevalent in patients with idiopathic pulmonary fibrosis (IPF) or sarcoidosis. However, the difference in fatigue perceptions for these patients is unknown and this may be important to better understand what fatigue means to the individual patient.

Methods

This cross-sectional quantitative study aims to determine the different perceptions of fatigue as 'frustrating', 'exhausting', 'pleasant', 'frightening' using the Fatigue Quality List and to assess determinants related to these perceptions of fatigue. Beside the fatigue quality connotations, demographics, lung function, fatigue severity (Checklist Individual Strength subscale Fatigue), dyspnea (modified-Medical Research Council), fatigue catastrophizing (Fatigue Catastrophizing Scale), anxiety/depression (Hospital Anxiety and Depression Scale) and general health status (EuroQoL 5-dimension 5-level) were assessed.

Results

Mean frequency score of fatigue-related perceptions in patients with IPF was 3.4 points and in patients with sarcoidosis 4.0 points. Severely fatigued patients with IPF reported their fatigue less 'pleasant' significantly more often than patients without severe fatigue. Fatigue severity, dyspnea, catastrophizing and general health were significantly correlated with the negative connotation categories of the Fatigue Quality List in patients with IPF. Severely fatigued sarcoidosis patients reported their fatigue perceptions significantly more often as 'frustrating', 'exhausting', 'frightening' and less 'pleasant' than patients without severe fatigue. Moreover, in patients with sarcoidosis fatigue severity, dyspnea, catastrophizing and depression were significantly associated with all four categories of the Fatigue Quality List that describe the experienced fatigue (P<0.05).

Conclusions

The current findings of experiences of fatigue in patients with IPF or pulmonary sarcoidosis provide insights for professionals treating these patients. Although similarities were found in the several experiences of fatigue across non-severely and severely fatigued patients, differences were also evident and could be mapped for IPF and sarcoidosis.

Feasibility of investigating methylphenidate for the treatment of sarcoidosis-associated fatigue (the FaST-MP study): a double-blind, parallel-arm randomised feasibility trial

Introduction

Sarcoidosis-associated fatigue (SAF) is a common clinical problem with limited treatment options. This study was undertaken to determine the feasibility of performing a definitive trial to determine the clinical efficacy methylphenidate in SAF.

Methods

This was a parallel-arm, double-blind, placebo-controlled randomised controlled feasibility trial enrolling sarcoidosis patients reporting significant fatigue. Patients with a Fatigue Assessment Scale score of more than 21 were randomised to receive up to either 10 mg two times per day methylphenidate or identical placebo capsules two times per day, in a dose escalation fashion, for up to 24 weeks. Outcomes included number of participants eligible and willing to participate, withdrawal rates, adherence rates and ability to maintain blinding.

Results

Of 385 patients screened, 56 (14.5%) were eligible and 23 (41% of eligible patients) were randomised. No withdrawals occurred. One participant in the methylphenidate arm discontinued study medications due to chest pain. The side effect profile was not different between the groups. Median medication adherence rates were 98% and 99% in the methylphenidate and placebo arms, respectively. A greater proportion of participants receiving methylphenidate predicted their allocated treatment while blinded compared with those receiving placebo (93.3% vs 57.1%). The investigator could not predict the treatment allocation. Both groups showed clinically meaningful improvements in fatigue from baseline, although no between-group difference was seen.

Conclusions

The data support the feasibility of performing a double-blind parallel trial powered to determine the clinical efficacy of methylphenidate for SAF, however, a multicentre study will be required.

Trial registration number

NCT02643732.

The Burden of Neurosarcoidosis: Essential Approaches to Early Diagnosis and Treatment

Neurosarcoidosis (NS) is an often severe, destructive manifestation with a likely under-reported prevalence of 5 to 15% of sarcoidosis cases, and in its active phase demands timely treatment intervention. Clinical signs and symptoms of NS are variable and wide-ranging, depending on anatomical involvement. Cranial nerve dysfunction, cerebrospinal parenchymal disease, aseptic meningitis, and leptomeningeal disease are the most commonly recognized manifestations. However, non-organ-specific potentially neurologically driven symptoms, such as fatigue, cognitive dysfunction, and small fiber neuropathy, appear frequently.Heterogeneous clinical presentations and absence of any single conclusive test or biomarker render NS, and sarcoidosis itself, a challenging definitive diagnosis. Clinical suspicion of NS warrants a thorough systemic and neurologic evaluation hopefully resulting in supportive extraneural physical exam and/or tissue findings. Treatment targets the severity of the manifestation, with careful discernment of whether NS reflects active potentially reversible inflammatory granulomatous disease versus inactive postinflammatory damage whereby functional impairment is unlikely to be pharmacologically responsive. Non-organ-specific symptoms are poorly understood, challenging in deciphering reversibility and often identified too late to respond to conventional immunosuppressive/pharmacological treatment. Physical therapy, coping strategies, and stress reduction may benefit patients with all disease activity levels of NS.This publication provides an approach to screening, diagnosis, disease activity discernment, and pharmacological as well as nonpharmacological treatment interventions to reduce disability and protect health-related quality of life in NS.

Health-Related Quality of Life in Sarcoidosis

Health-related quality of life (HRQoL) describes an individual's perception of the impact of health, disease, and treatment on their quality of life (QoL). It is a reflection of how the manifestation of an illness and its treatment is personally experienced. Assessing HRQoL is particularly important in sarcoidosis because the attributable disease mortality is relatively low, and one of the major reasons for initiating treatment is to improve quality of life. HRQoL has been assessed in sarcoidosis using various generic and sarcoid-specific patient-reported outcome measures (PROMs). It is important that both the direct and indirect effects of the disease, as well as potential toxicities of therapy, are captured in the various PROMs used to assess HRQoL in sarcoidosis. This article provides a general overview of HRQoL in patients with sarcoidosis. It describes the various PROMs used to assess HRQoL in sarcoidosis and addresses the various factors that influence HRQoL in sarcoidosis. Specific attention is paid to fatigue, small fiber neuropathy, corticosteroid therapy, and other disease-specific factors that affect HRQoL in sarcoidosis. It also provides an insight into interventions that have been associated with improved HRQoL in sarcoidosis and offers suggestions for future research in this important area.

Nonorgan manifestations of sarcoidosis

PURPOSE OF REVIEW

The current review discusses the diagnosis and management of nonorgan-related symptoms that commonly arise in the setting of systemic sarcoidosis. Fatigue, small fiber neuropathy (SFN) and neuropsychological symptoms are highlighted.

RECENT FINDINGS

The debilitating effects of chronic nonorgan-based symptoms in sarcoidosis have led to recent studies focusing on incidence rates, contributing factors and potential therapeutic strategies. In a web-based survey of over 1000 sarcoidosis patients, the most common symptom was fatigue, which was reported by over 90% of participants, whereas memory loss and concentration problems were reported in 50%. SFN was also common, and may be diagnosed with tools such as skin biopsy measurement of intraepidermal nerve fibers and corneal confocal microscopy. In a recent cohort study of SFN patients, serologic evaluation demonstrated other contributing causes such as diabetes and vitamin B12 deficiency, which warrant-specific treatment. Finally, physical inactivity in patients with sarcoidosis correlated with lower quality-of-life (QOL) scores and possibly fatigue. Multidisciplinary programs that include physical therapy, patient education and psychological support were found to improve fatigue and mood disorders.

SUMMARY

Recognition of nonorgan-related symptoms and their impact on patient QOL is essential to optimal treatment of the sarcoidosis patient.

Quality of Life of Couples Living with Sarcoidosis

BACKGROUND

Consequences of sarcoidosis are wide ranging, and the symptom burden has a great impact on patients' quality of life (QoL). However, the QoL of couples living with sarcoidosis has not yet been studied.

OBJECTIVES

Our aim was to assess the QoL of couples living with sarcoidosis and to evaluate whether living with a partner with sarcoidosis influences the partner's QoL. Furthermore, we aimed to assess whether nonspecific symptoms (fatigue, cognitive failure, small fiber neuropathy (SFN)-related symptoms, depressive symptoms, and state/trait anxiety) predict QoL of partners as well as sarcoidosis patients.

METHOD

Sarcoidosis outpatients, recruited at Maastricht University Medical Centre (n = 443), and their partners (n = 208) completed several questionnaires, including the World Health Organization QoL - BREF, Fatigue Assessment Scale, SFN screening list, and cognitive failure questionnaire.

RESULTS

QoL of the partners as well as the sarcoidosis patients was reduced compared with healthy controls, especially regarding the physical health domain. All nonspecific symptoms studied, as well as perceived social support, predicted one or more QoL domains in the sarcoidosis patients, but these factors did not predict the QoL of their partners.

CONCLUSIONS

The QoL of partners of sarcoidosis patients was reduced, although to a lesser extent than that of the patients. Although the nonspecific symptoms and perceived social support were related to the patients' QoL, this was not the case for the partners. In the management of sarcoidosis, it is important to focus not only on the patients but also on their partners.

The Fatigue Assessment Scale: quality and availability in sarcoidosis and other diseases

PURPOSE OF REVIEW

Fatigue is a problem experienced by many patients suffering from chronic diseases, including sarcoidosis patients. It has a substantial influence on patients' quality of life (QoL). It is, therefore, important to properly assess fatigue with a valid and reliable measure. The Fatigue Assessment Scale (FAS) is the only validated self-reporting instrument classifying fatigue in sarcoidosis. The aim of this review was to examine the psychometric properties of the FAS and the diseases and languages in which it has been used. Studies among sarcoidosis patients were also reviewed in terms of outcomes.

RECENT FINDINGS

Studies were identified by searching the electronic bibliographic database Pubmed. Search terms used were: FAS and fatigue. Articles were included in the review if the FAS had been used to assess fatigue.

RESULTS

Since its introduction, the FAS was used in 26 different diseases or conditions, including stroke, neurologic disorders, rheumatoid arthritis, idiopathic pulmonary fibrosis and sarcoidosis. Its reliability and validity have proved to be good. Unidimensionality has been established. So far, the FAS is available in 20 languages and widely used in sarcoidosis. Digital versions as well as PDFs of various languages are available online (www.wasog.org).

SUMMARY

The FAS has good psychometric qualities for the diseases in which it has been examined, including sarcoidosis, and can be used in clinical practice. Healthcare workers can use the FAS to assess fatigue in the management, follow-up and clinical care programmes for their patients consistently across countries, as well as in clinical research.

Feasibility, utility and symptom impact of modified mindfulness training in sarcoidosis

Sarcoidosis is a multisystem disorder characterised by noncaseating granulomatous inflammation of unknown aetiology. It may resolve spontaneously, but ∼30% of patients have progressive disease with significant organ damage [1]. Although any organ is vulnerable, the lungs are frequently involved resulting in shortness of breath and dry cough. Fatigue is an overarching symptom in sarcoidosis, originating from multiple and combined causes of mental fatigue and physical fatigue [2]. This is also true of the psychosocial impact of sarcoidosis, which may include depression, anxiety, isolation and feelings of uncertainty. The prevalence of these factors remains high even for those who achieve clinical remission, resulting in psychological distress and reduced health status [3].

A modified mindfulness-based exercise intervention has beneficial impact on people living with sarcoidosishttp://ow.ly/XYTO30jtmms

Feasibility study of a randomised controlled trial to investigate the treatment of sarcoidosis-associated fatigue with methylphenidate (FaST-MP): a study protocol

INTRODUCTION

Fatigue is a frequent and troublesome manifestation of chronic sarcoidosis. This symptom can be debilitating and difficult to treat, with poor response to the treatment. Symptomatic management with neurostimulants, such as methylphenidate, is a possible treatment option. The use of such treatment strategies is not without precedent and has been trialled in cancer-related fatigue. Their use in sarcoidosis requires further evaluation before it can be recommended for clinical practice.

METHODS AND ANALYSIS

The Fatigue and Sarcoidosis-Treatment with Methylphenidate study is a randomised, controlled, parallel-arm and feasibility trial of methylphenidate for the treatment of sarcoidosis-associated fatigue. Patients are eligible if they have a diagnosis of sarcoidosis, significant fatigue (measured using the Fatigue Assessment Scale) and have stable disease. Up to 30 participants will be randomly assigned to either methylphenidate (20 mg two times per day) or identical placebo in a 3:2 ratio for 24 weeks. The primary objective is to collect data determining the feasibility of a future study powered to determine the clinical efficacy of methylphenidate for sarcoidosis-associated fatigue. The trial is presently open and will continue until July 2018.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by the Cambridge Central Research Ethics Committee on 21 June 2016 (reference 16/EE/0087) and was approved and sponsored by the Norfolk and Norwich University Hospital (reference 190280). Clinical Trial Authorisation (EudraCT number 2016-000342-60) from the Medicines and Healthcare products Regulatory Agency (MHRA) was granted on 19 April 2016. Results will be presented at relevant conferences and submitted to appropriate journals following trial closure and analysis.

TRIAL REGISTRATION NUMBER

NCT02643732; Pre-results.

Disease Burden and Variability in Sarcoidosis

Sarcoidosis is a systemic inflammatory disease with substantial morbidity and increasing mortality. As part of the National Heart, Lung, and Blood Institute's workshop to better understand this disease and improve the outcomes of patients with sarcoidosis, we reviewed the available data on health care burden and outcomes of this disease in the United States. Disparities in outcomes exist by race, ethnicity, sex, and socioeconomic groups, with African Americans having disproportionately more severe disease. Mortality rates are highest in African Americans, but may be increasing in white individuals. The health care burden of sarcoidosis is defined not only by its somatic manifestations, but is also greatly impacted by psychosocial, economic, and comorbid conditions associated with this disease. Fatigue, depression, cognitive dysfunction, treatment side effects, and pain syndromes are highly prevalent in this population and contribute to poor outcomes. The direct and indirect economic costs to patients and society are likely also substantial, although not well defined. We recommend leveraging existing and future technology and infrastructure to more accurately define and monitor the overall total sarcoidosis-attributable health care burden and patient outcomes in the United States.

Patient reported outcome measures (PROMs) in sarcoidosis

Patients with sarcoidosis present with a variety of symptoms which may impair many aspects of physical and mental well-being. Traditionally, clinicians have been concerned with physical health aspects of sarcoidosis, assessing disease activity and severity with radiological imaging, pulmonary function and blood tests. However, the most reported symptom of sarcoidosis patients, fatigue, has been shown not to correlate with the most commonly used parameters for monitoring disease activity. Studies have shown poor agreement between physicians and patients in assessing sarcoidosis symptoms. This underlines the importance of patient reported outcomes (PROs) in addition to traditional outcomes in order to provide a complete evaluation of the effects of interventions in clinical trials and everyday clinical assessment of sarcoidosis. We have undertaken a systematic review to identify and provide an overview of PRO concepts used in sarcoidosis assessment the past 20 years and to evaluate the tools used for measuring these concepts, called patient reported outcome measures (PROMs). Various PROMs have been used. By categorizing these PROMs according to outcome we identified the key PRO concepts for sarcoidosis to be Health Status and Quality of Life, Dyspnea, Fatigue, Depression, Anxiety and Stress and Miscellaneous. There is no perfect sarcoidosis-specific PROM to cover all concepts and future intervention studies should therefore contain multiple complementary questionnaires. Based on our findings we recommend the Fatigue Assessment Scale (FAS) for assessing fatigue. Dyspnea scores should be chosen based on their purpose; more research is needed to examine their validity in sarcoidosis. The Modified Medical Research Council Dyspnea Scale (MRC) can be used to screen for dyspnea and the Baseline Dyspnea Index (BDI) to detect changes in dyspnea. We recommend The World Health Organization Quality of Life assessment instrument (WHOQOL-100) for assessing quality of life, although a shorter questionnaire would be preferable. For assessing health status we recommend the Sarcoidosis Assessment Tool (SAT), and have great expectations for this new and promising assessment tool. Supplementary to the WASOG meeting of 2011's recommendation on assessing QoL, we recommend incorporating fatigue, dyspnea and HS assessment in clinical trials and everyday clinical assessment of sarcoidosis. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 2-17).

Interrelationship between sleep-disordered breathing and sarcoidosis

Sleep-disordered breathing (SDB) has a high prevalence in sarcoidosis. This high prevalence may be the result of increased upper airways resistance from sarcoidosis of the upper respiratory tract, corticosteroid-induced obesity, or parenchymal lung involvement from sarcoidosis. OSA is a form of SDB that is particularly common in patients with sarcoidosis. Sarcoidosis and SDB share many similar symptoms and clinical findings, including fatigue, gas exchange abnormalities, and pulmonary hypertension (PH). Sarcoidosis-associated fatigue is a common entity for which stimulants may be beneficial. Sarcoidosis-associated fatigue is a diagnosis of exclusion that requires an evaluation for the possibility of OSA. Hypercapnia is unusual in a patient with sarcoidosis without severe pulmonary dysfunction and, in this situation, should prompt evaluation for alternative causes of hypercapnia, such as SDB. PH is usually mild when associated with OSA, whereas the severity of sarcoidosis-associated PH is related to the severity of sarcoidosis. PH caused by OSA usually responds to CPAP, whereas sarcoidosis-associated PH commonly requires the use of vasodilators. Management of OSA in sarcoidosis is problematic because corticosteroid treatment of sarcoidosis may worsen OSA. Aggressive efforts should be made to place the patient on the lowest effective dose of corticosteroids, which involves early consideration of corticosteroid-sparing agents. Because of the significant morbidity associated with SDB, early recognition and treatment of SDB in patients with sarcoidosis may improve their overall quality of life.

Worsening of pulmonary sarcoidosis

PURPOSE OF REVIEW

Despite the frequent occurrence of worsening pulmonary symptoms in pulmonary sarcoidosis patients, there is little available information concerning this topic.

RECENT FINDINGS

In this review, we outline the various causes for these symptoms. We propose to partition the various causes for these symptoms into specific categories.

SUMMARY

We believe that these categories will provide the clinician a framework to evaluate pulmonary sarcoidosis patients with such symptoms in a rigorous way that may be useful in optimizing their care.

Development of a clinician-administered National Institutes of Health-Brief Fatigue Inventory: A measure of fatigue in the context of depressive disorders

OBJECTIVE

Fatigue is a complex, multidimensional condition. Although it is often associated with depression, it is not known whether it has a distinct network from depression or whether it can be clinically evaluated, separately. This study describes preliminary findings in the development of a brief, clinician-administered instrument to measure fatigue in the context of depressive disorders using items from existing clinician-administered depression and mania scales.

METHODS

Based on items from prior fatigue measurements, items were selected from the Hamilton Depression Rating Scale (HDRS), Montgomery-Asberg Depression Rating Scale (MADRS), Young Mania Rating Scale, and Structured Interview Guide for HDRS with Atypical Depression. The final items composed the NIH-Brief Fatigue Inventory (NIH-BFI). Responses from 89 depressed adults collected pre- and post-antidepressant therapy (ADT) determined the reliability and consistency of the NIH-BFI using Cronbach's alpha and principal components analysis (PCA). Correlations of the NIH-BFI and fatigue items from other scales before and after ADT explored validity.

RESULTS

The 7-item NIH-BFI had Cronbach alphas ranging from 0.81 to 0.88 and PCA indicating a single dimension. The NIH-BFI score was strongly correlated (r = 0.73, p < 0.001) with fatigue items from Beck Depression Index, with MADRS without fatigue items (r = 0.77, p < 0.001), and HDRS without fatigue items (pre: r = 0.69, p < 0.001).

CONCLUSIONS

Preliminary findings show support for internal consistency reliability and validity of the NIH-BFI, a clinician-administered measure of fatigue. Further testing in other clinical populations is recommended to obtain additional information on reliability and validity. The NIH-BFI provides a method for clinician-rated fatigue that may be a separate from depression.

Subjective sleep quality in sarcoidosis

BACKGROUND

Poor sleep is common among patients with medical disorders. Sleep disturbances can be a cause of fatigue and poor quality of life for patients suffering from sarcoidosis. Studies on subjective sleep quality or prevalence of insomnia have not been reported so far.

OBJECTIVES

The aim of this study was to investigate the subjectively reported sleep quality and its relation to psychological and physical factors in sarcoidosis patients.

METHODS

1197 patients from Germany diagnosed with sarcoidosis were examined using the Pittsburgh Sleep Quality Index (PSQI), the Medical Research Council (MRC) dyspnea scale, the Hospital Anxiety and Depression Scale (HADS) and the Multidimensional Fatigue Inventory (MFI).

RESULTS

802 patients (67%) had PSQI global scores >5, indicating subjectively poor quality of sleep. The mean PSQI score was 7.79 ± 4.00. Women reported a significantly inferior individual quality of sleep than men. The subjective quality of sleep was lowered significantly with increasing dyspnea for men and women. 294 patients (25%) had PSQI global scores >10 usually found in patients with clinically relevant insomnia. In this group 86% had high values for fatigue, 69% for anxiety, and 59% for depression. The prevalence of known sleep apnea was 8.7% and 15.7% for restless legs.

CONCLUSION

Poor subjective sleep quality in sarcoidosis patients is about twice as common as in the general population and is associated with fatigue, anxiety, depression and dyspnea. Questions about sleep complaints should therefore be included in the management of sarcoidosis.

Approaches to the treatment of some of the troublesome manifestations of sarcoidosis

Sarcoidosis can be a major therapeutic challenge given its multiplicity of clinical presentations, variable combination of organ involvement and severity, and unpredictable longitudinal behaviour. Six manifestations of sarcoidosis are especially difficult to manage because of (i) an incomplete knowledge of causation - fatigue and small fibre neuropathy, (ii) the rare occurrence in sarcoidosis - intra-abdominal complications or (iii) the potentially life-threatening consequences in some patients - neurological disease, pulmonary hypertension and hypercalcaemia. In none of these situations have a prospective, double-blind, placebo-controlled trial of any therapy been conducted. Despite this absence of any firm evidence base to support therapeutic recommendations, these six entities can be extremely problematic for the practising clinician. It is for this reason that we have focused in this review on these six disease manifestations and provided a synopsis of each problem together with suggested treatment approaches, based on an analysis of the current literature.

Development and testing of item response theory-based item banks and short forms for eye, skin and lung problems in sarcoidosis

PURPOSE

Sarcoidosis is a multisystem disease that can negatively impact health-related quality of life (HRQL) across generic (e.g., physical, social and emotional wellbeing) and disease-specific (e.g., pulmonary, ocular, dermatologic) domains. Measurement of HRQL in sarcoidosis has largely relied on generic patient-reported outcome tools, with little disease-specific measures available. The purpose of this paper is to present the development and testing of disease-specific item banks and short forms of lung, skin and eye problems, which are a part of a new patient-reported outcome (PRO) instrument called the sarcoidosis assessment tool.

METHODS

After prioritizing and selecting the most important disease-specific domains, we wrote new items to reflect disease-specific problems by drawing from patient focus group and clinician expert survey data that were used to create our conceptual model of HRQL in sarcoidosis. Item pools underwent cognitive interviews by sarcoidosis patients (n = 13), and minor modifications were made. These items were administered in a multi-site study (n = 300) to obtain item calibrations and create calibrated short forms using item response theory (IRT) approaches.

RESULTS

From the available item pools, we created four new item banks and short forms: (1) skin problems, (2) skin stigma, (3) lung problems, and (4) eye Problems. We also created and tested supplemental forms of the most common constitutional symptoms and negative effects of corticosteroids.

CONCLUSIONS

Several new sarcoidosis-specific PROs were developed and tested using IRT approaches. These new measures can advance more precise and targeted HRQL assessment in sarcoidosis clinical trials and clinical practice.