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Hasan Z, Kuyvenhoven C, Chowdhury M, Amoudi L, Zeraatkar D, Busse JW, Sadik M, Vanstone M. Patient perspectives of recovery from myalgic encephalomyelitis/chronic fatigue syndrome: An interpretive description study. J Eval Clin Pract 2024; 30:234-242. [PMID: 37927138 DOI: 10.1111/jep.13938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/12/2023] [Accepted: 10/19/2023] [Indexed: 11/07/2023]
Abstract
AIMS AND OBJECTIVES Myalgic encephalomyelitis (ME), also called chronic fatigue syndrome (CFS), is characterised by persistent fatigue, postexertional malaise, and cognitive dysfunction. It is a complex, long-term, and debilitating illness without widely effective treatments. This study describes the treatment choices and experiences of ME/CFS patients who have experienced variable levels of recovery. METHOD Interpretive description study consisting of semi-structured qualitative interviews with 33 people who met the US Centers for Disease Control (2015) diagnostic criteria for ME/CFS and report recovery or symptom improvement. RESULTS Twenty-six participants endorsed partial recovery, and seven reported full recovery from ME/CFS. Participants reported expending significant time and energy to identify, implement, and adapt therapeutic interventions, often without the guidance of a medical practitioner. They formulated individualised treatment plans reflecting their understanding of their illness and personal resources. Most fully recovered participants attributed their success to mind-body approaches. CONCLUSION Patients with ME/CFS describe independently constructing and managing treatment plans, due to a lack of health system support. Stigmatised and dismissive responses from clinicians precipitated disengagement from the medical system and prompted use of other forms of treatment.
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Affiliation(s)
- Zara Hasan
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Mehreen Chowdhury
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lana Amoudi
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dena Zeraatkar
- Department of Anesthesiology, McMaster University, Hamilton, Ontario, Canada
| | - Jason W Busse
- Department of Anesthesiology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Marina Sadik
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Minotti C, McKenzie C, Dewandel I, Bekker C, Sturniolo G, Doni D, Giaquinto C, Van Der Zalm MM, Donà D. How does post COVID differ from other post-viral conditions in childhood and adolescence (0-20 years old)? A systematic review. EClinicalMedicine 2024; 68:102436. [PMID: 38333536 PMCID: PMC10850405 DOI: 10.1016/j.eclinm.2024.102436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/03/2024] [Accepted: 01/10/2024] [Indexed: 02/10/2024] Open
Abstract
Background Post Coronavirus disease (COVID) and other post-viral infection syndromes present an overlap of pathogenesis, onset, progression, and symptom profile. We aimed to systematically describe studies on post-viral conditions and determine the entity of post COVID compared to other post-viral conditions in children. Methods We conducted a systematic search of the Embase, MEDLINE, Cochrane Library, and GoogleScholar databases (January 1946-3 November 2023), according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The main outcomes were differences in condition duration, symptom type, and development of chronic symptoms. This systematic review was registered on PROSPERO (CRD42023401789). Findings 35/5051 studies were included, with 42,934 children, adolescents and young adults (0-20 years old) overall. Twenty-eight studies focused on post COVID symptoms, followed by five papers on Respiratory Syncytial Virus (RSV) and Rhinovirus, one study on Epstein-Barr Virus (EBV), and one on gastrointestinal viruses. Studies on post COVID mainly reported data on older children/adolescents, describing long-lasting symptoms, including fatigue, neurologic, cardiorespiratory, musculoskeletal, mental health, and gastrointestinal symptoms. The maximum described symptoms duration was eighteen months, with an average follow-up of seven months. The development of chronic symptoms was reported by 30 studies (93.8%) for 10,473/28,474 patients (36.8%). Recovery was achieved in 18,001/28,474 cases (63.2%). The study on EBV reported persistent fatigue in adolescents for a similar duration (6 months, 46% chronic). Studies on RSV and Rhinovirus were mainly done in children under three years, with development of recurrent wheezing (up to 3 years). Interpretation Post-viral fatigue was a shared feature between post COVID and post EBV conditions. A better understanding of post COVID as a unique condition, sharing features with other post-viral syndromes, is needed. The healthcare burden and socio-economic consequences for children and their families warrant further investigation and development of appropriate healthcare management plans. The foremost requirement is the establishment of consistent and shareable definitions, as well as a consensus on outcomes, to effectively evaluate follow-up and quantify the burden of different viral infections. Funding EU Horizon, EDCTP, NIH.
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Affiliation(s)
- Chiara Minotti
- Department of Women's and Children's Health, University of Padua, Italy
- PhD Program in Clinical Research, University Children's Hospital Basel, University of Basel, Switzerland
| | - Carla McKenzie
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Isabelle Dewandel
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Carien Bekker
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Giulia Sturniolo
- Department of Women's and Children's Health, University of Padua, Italy
| | - Denis Doni
- Department of Women's and Children's Health, University of Padua, Italy
| | - Carlo Giaquinto
- Department of Women's and Children's Health, University of Padua, Italy
| | - Marieke M. Van Der Zalm
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Daniele Donà
- Department of Women's and Children's Health, University of Padua, Italy
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Luo H, Gong R, Zheng R, Tan J, Chen R, Wu J, Ma T. Dose-effect of long-snake-like moxibustion for chronic fatigue syndrome: a randomized controlled trial. J Transl Med 2023; 21:430. [PMID: 37400824 DOI: 10.1186/s12967-023-04250-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/06/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND The dose-effect relationship of Long-snake-like moxibustion for chronic fatigue syndrome (CFS) remains poorly understood. In order to address this gap, we designed this trial to assess the association between different treatment duration of Long-snake-like moxibustion and its effects on CFS based on the combination measurements of the subjective patient-reported scales with objective medical infrared imaging technology─Thermal Texture Maps (TTM). METHODS From December 2020 to January 2022, 60 female CFS patients were recruited and equally allocated to two groups: Group A, receiving 60-min Long-snake-like moxibustion per treatment, and Group B, receiving 30-min Long-snake-like moxibustion per treatment. The treatment was administered 3 times per week for a total of 4 weeks. The primary outcome was defined as the improvement of symptoms measured by the Fatigue scale-14 (FS-14), and secondary outcomes were designated as the improvement in Symptoms Scale of Spleen-Kidney Yang Deficiency, Self-rating depression scale, and Self-rating anxiety scale. TTM scanning was employed twice for CFS patients (before and after 4-week treatment) and once for Healthy control subjects (HCs). RESULTS At week 4, the scores of FS-14 and Symptoms Scale of Spleen-Kidney Yang Deficiency in Group A were significantly lower than those in Group B (physical fatigue: 5.00 vs. 6.00, with 95%CI - 2.00 to 0.00, p = 0.003; FS-14 total score: 8.00 vs. 9.00, with 95%CI - 3.00 to 0.00, p = 0.012; total score of Symptoms Scale of Spleen-Kidney Yang Deficiency: 9.80 vs. 13.07, with 95%CI - 5.78 to - 0.76, P = 0.012). All thermal radiation values of the two groups increased, and statistical differences in ΔTs between Group A and HCs were not obtained. More significant correlations between symptoms improvements and ΔT changes were observed in Group A, and its ΔT changes in Upper Jiao, Shenque (CV8), Zhongwan (CV12), Danzhong (CV17), Zhiyang (GV9), Dazhui (GV14), upper arm, thoracic segments, lumbar segments, renal region, popliteal fossa strongly correlated with the improvement of Spleen-Kidney Yang Deficiency symptoms. CONCLUSIONS In the same course of treatment, the positive dose-effect relationship was found between the treatment duration of Long-snake-like moxibustion and CFS effect assessment. 60-min Long-snake-like moxibustion per treatment were associated with optimal clinical response and TTM improvement. TRIAL REGISTRATION Chinese Clinical Trail Registry (No. ChiCTR2000041000, date of registration: 16 December 2020), http://www.chictr.org.cn/showproj.aspx?proj=62488.
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Affiliation(s)
- Hong Luo
- College of Acupuncture and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China
| | - Rui Gong
- College of Acupuncture and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China
| | - Rui Zheng
- College of Acupuncture and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China
| | - Jing Tan
- Center of Chinese Evidence-Based Medicine, Sichuan University West China Hospital, Chengdu, 610041, China
| | - Ruixue Chen
- College of Acupuncture and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China
| | - Jie Wu
- Center of Preventive Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China
| | - Tingting Ma
- Center of Preventive Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China.
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Maya J, Leddy SM, Gottschalk CG, Peterson DL, Hanson MR. Altered Fatty Acid Oxidation in Lymphocyte Populations of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Int J Mol Sci 2023; 24:2010. [PMID: 36768336 PMCID: PMC9916395 DOI: 10.3390/ijms24032010] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/14/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a disabling multisystem illness in which individuals are plagued with fatigue, inflammatory symptoms, cognitive dysfunction, and the hallmark symptom, post-exertional malaise. While the cause of this disease remains unknown, there is evidence of a potential infectious component that, along with patient symptoms and common onsets of the disease, implicates immune system dysfunction. To further our understanding of the state of ME/CFS lymphocytes, we characterized the role of fatty acids in isolated Natural Killer cells, CD4+ T cells, and CD8+ T cells in circulation and after overnight stimulation, through implicit perturbations to fatty acid oxidation. We examined samples obtained from at least 8 and as many as 20 subjects for immune cell fatty acid characterization in a variety of experiments and found that all three isolated cell types increased their utilization of lipids and levels of pertinent proteins involved in this metabolic pathway in ME/CFS samples, particularly during higher energy demands and activation. In T cells, we characterized the cell populations contributing to these metabolic shifts, which included CD4+ memory cells, CD4+ effector cells, CD8+ naïve cells, and CD8+ memory cells. We also discovered that patients with ME/CFS and healthy control samples had significant correlations between measurements of CD4+ T cell fatty acid metabolism and demographic data. These findings provide support for metabolic dysfunction in ME/CFS immune cells. We further hypothesize about the consequences that these altered fuel dependencies may have on T and NK cell effector function, which may shed light on the illness's mechanism of action.
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Affiliation(s)
- Jessica Maya
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY 14850, USA
| | - Sabrina M. Leddy
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY 14850, USA
| | | | - Daniel L. Peterson
- Simmaron Research, Incline Village, NV 89451, USA
- Sierra Internal Medicine, Incline Village, NV 89451, USA
| | - Maureen R. Hanson
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY 14850, USA
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5
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Meade E, Garvey M. The Role of Neuro-Immune Interaction in Chronic Pain Conditions; Functional Somatic Syndrome, Neurogenic Inflammation, and Peripheral Neuropathy. Int J Mol Sci 2022; 23:ijms23158574. [PMID: 35955708 PMCID: PMC9369187 DOI: 10.3390/ijms23158574] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/30/2022] [Accepted: 07/31/2022] [Indexed: 02/01/2023] Open
Abstract
Functional somatic syndromes are increasingly diagnosed in chronically ill patients presenting with an array of symptoms not attributed to physical ailments. Conditions such as chronic fatigue syndrome, fibromyalgia syndrome, or irritable bowel syndrome are common disorders that belong in this broad category. Such syndromes are characterised by the presence of one or multiple chronic symptoms including widespread musculoskeletal pain, fatigue, sleep disorders, and abdominal pain, amongst other issues. Symptoms are believed to relate to a complex interaction of biological and psychosocial factors, where a definite aetiology has not been established. Theories suggest causative pathways between the immune and nervous systems of affected individuals with several risk factors identified in patients presenting with one or more functional syndromes. Risk factors including stress and childhood trauma are now recognised as important contributors to chronic pain conditions. Emotional, physical, and sexual abuse during childhood is considered a severe stressor having a high prevalence in functional somatic syndrome suffers. Such trauma permanently alters the biological stress response of the suffers leading to neuroexcitatory and other nerve issues associated with chronic pain in adults. Traumatic and chronic stress results in epigenetic changes in stress response genes, which ultimately leads to dysregulation of the hypothalamic-pituitary axis, the autonomic nervous system, and the immune system manifesting in a broad array of symptoms. Importantly, these systems are known to be dysregulated in patients suffering from functional somatic syndrome. Functional somatic syndromes are also highly prevalent co-morbidities of psychiatric conditions, mood disorders, and anxiety. Consequently, this review aims to provide insight into the role of the nervous system and immune system in chronic pain disorders associated with the musculoskeletal system, and central and peripheral nervous systems.
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Affiliation(s)
- Elaine Meade
- Department of Life Science, Atlantic Technological University, F91 YW50 Sligo, Ireland;
| | - Mary Garvey
- Department of Life Science, Atlantic Technological University, F91 YW50 Sligo, Ireland;
- Centre for Precision Engineering, Materials and Manufacturing Research (PEM), Atlantic Technological University, F91 YW50 Sligo, Ireland
- Correspondence:
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De Nardi L, Lanzetta MA, Ghirigato E, Barbi E, Gortani G. Approach to the child with fatigue: A focus for the general pediatrician. Front Pediatr 2022; 10:1044170. [PMID: 36533226 PMCID: PMC9755349 DOI: 10.3389/fped.2022.1044170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/16/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Fatigue is a common, nonspecific complaint commonly used to describe various conditions, ranging from a vague, subjective sense of weariness to muscular weakness, fatigability, exercise intolerance or excessive daytime somnolence. Despite its high frequency in the general population, literature addressing the approach to the child with fatigue from a general pediatrician perspective is poor. We herein propose a review of the available evidence on the topic, providing a practical framework to assist physicians in dealing with the issue. METHODS Data were identified by searches of MEDLINE, UpToDate, Google Scholar and references from relevant articles. Articles published between 1990 and 2021 were considered, prioritizing systematic reviews and meta-analyses. Then, an empirically-based model of approaching the tired child was proposed according to our center experience. RESULTS To correctly characterize the meaning of fatigue reporting, specific clues from history and physical examination should be emphasized. Duration, severity, and the age at onset are to be considered. Then, specific queries about everyday activities, sleep hygiene and social domain could be useful in reaching a specific diagnosis and offering an appropriate treatment. CONCLUSIONS We suggest a pragmatic approach to fatigue in children based on age assessment, targeted questions, physical examination clues, and some laboratory first-level tests. This could provide pediatricians with a useful tool to discriminate the broad etiology of such a complaint, disentangling between psychological and organic causes. Further studies are needed to investigate the predictive value, specificity and sensitivity of this diagnostic workflow in managing the child with fatigue.
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Affiliation(s)
- Laura De Nardi
- University of Trieste, Clinical Department of Medical Surgical and Health Science, Trieste, Italy
| | - Maria Andrea Lanzetta
- University of Trieste, Clinical Department of Medical Surgical and Health Science, Trieste, Italy.,Department of Pediatrics, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Elena Ghirigato
- University of Trieste, Clinical Department of Medical Surgical and Health Science, Trieste, Italy
| | - Egidio Barbi
- University of Trieste, Clinical Department of Medical Surgical and Health Science, Trieste, Italy.,Department of Pediatrics, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Giulia Gortani
- Department of Pediatrics, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
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7
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Lim EJ, Lee JS, Lee EJ, Jeong SJ, Park HY, Ahn YC, Son CG. Nationwide epidemiological characteristics of chronic fatigue syndrome in South Korea. J Transl Med 2021; 19:502. [PMID: 34876158 PMCID: PMC8650266 DOI: 10.1186/s12967-021-03170-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/20/2021] [Indexed: 12/21/2022] Open
Abstract
Background Chronic fatigue syndrome (CFS) is a long-term disabling illness accompanied by medically unexplained fatigue. This study aimed to explore the epidemiological characteristics of CFS in South Korea. Methods Using the nationwide medical records provided by the Korean Health Insurance Review & Assessment Service (HIRA), we analyzed the entire dataset for CFS patients diagnosed by physicians in South Korea from January 2010 to December 2020. Results The annual mean incidence of CFS was estimated to be 44.71 ± 6.10 cases per 100,000 individuals [95% CI: 40.57, 48.76], and the prevalence rate was 57.70 ± 12.20 cases per 100,000 individuals [95% CI: 49.40, 65.79]. These two rates increased by 1.53- and 1.94-fold from 2010 to 2020, respectively, and showed an increasing trend with aging and an approximately 1.5-fold female predominance. Conclusions This study is the first to report the nationwide epidemiological features of CFS, which reflects the clinical reality of CFS diagnosis and care in South Korea. This study will be a valuable reference for studies of CFS in the future.
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Affiliation(s)
- Eun-Jin Lim
- Department of Integrative Medicine, Graduate School of Integrative Medicine, CHA University, 120 Haeryong-Ro, Kyeong-Gi, Pocheon, 11160, Republic of Korea
| | - Jin-Seok Lee
- Institute of Bioscience & Integrative Medicine, College of Korean Medicine, Daejeon Oriental Hospital of Daejeon University, Daedeok-Daero 176, Seo-Gu, Daejeon, 35235, Republic of Korea
| | - Eun-Jung Lee
- Department of Korean Rehabilitation Medicine, College of Korean Medicine, Daejeon University, Daedeok-Daero 176, Seo-Gu, Daejeon, 35235, Republic of Korea
| | - Seok-Ju Jeong
- Health Insurance Review & Assessment Service, Dunsanbuk-ro 121, Seo-Gu, Daejeon, 35236, Republic of Korea
| | - Ho-Young Park
- Health Insurance Review & Assessment Service, Dunsanbuk-ro 121, Seo-Gu, Daejeon, 35236, Republic of Korea
| | - Yo-Chan Ahn
- Department of Health Service Management, Daejeon University, 96-3 Yongun-Dong, Dong-Gu, 300-716, Daejeon, 34520, Republic of Korea
| | - Chang-Gue Son
- Institute of Bioscience & Integrative Medicine, College of Korean Medicine, Daejeon Oriental Hospital of Daejeon University, Daedeok-Daero 176, Seo-Gu, Daejeon, 35235, Republic of Korea.
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Profile of circulating microRNAs in myalgic encephalomyelitis and their relation to symptom severity, and disease pathophysiology. Sci Rep 2020; 10:19620. [PMID: 33184353 PMCID: PMC7665057 DOI: 10.1038/s41598-020-76438-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/28/2020] [Indexed: 12/19/2022] Open
Abstract
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex chronic disease, rooted in multi-system dysfunctions characterized by unexplained debilitating fatigue. Post-exertional malaise (PEM), defined as the exacerbation of the patient's symptoms following minimal physical or mental stress, is a hallmark of ME/CFS. While multiple case definitions exist, there is currently no well-established biomarkers or laboratory tests to diagnose ME/CFS. Our study aimed to investigate circulating microRNA expression in severely ill ME/CFS patients before and after an innovative stress challenge that stimulates PEM. Our findings highlight the differential expression of eleven microRNAs associated with a physiological response to PEM. The present study uncovers specific microRNA expression signatures associated with ME/CFS in response to PEM induction and reports microRNA expression patterns associated to specific symptom severities. The identification of distinctive microRNA expression signatures for ME/CFS through a provocation challenge is essential for the elucidation of the ME/CFS pathophysiology, and lead to accurate diagnoses, prevention measures, and effective treatment options.
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Carr MJ, Ashcroft DM, White PD, Kapur N, Webb RT. Prevalence of comorbid mental and physical illnesses and risks for self-harm and premature death among primary care patients diagnosed with fatigue syndromes. Psychol Med 2020; 50:1156-1163. [PMID: 31131782 PMCID: PMC7253619 DOI: 10.1017/s0033291719001065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 04/02/2019] [Accepted: 04/23/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Fatigue syndromes (FSs) affect large numbers of individuals, yet evidence from epidemiological studies on adverse outcomes, such as premature death, is limited. METHODS Cohort study involving 385 general practices in England that contributed to the Clinical Practice Research Datalink (CPRD) with linked inpatient Hospital Episode Statistics (HES) and Office for National Statistics (ONS) cause of death information. A total of 10 477 patients aged 15 years and above, diagnosed with a FS during 2000-2014, were individually matched with up to 20 comparator patients without a history of having a FS. Prevalence ratios (PRs) were estimated to compare the FS and comparison cohorts on clinical characteristics. Adjusted hazard ratios (HRs) for subsequent adverse outcomes were estimated from stratified Cox regression models. RESULTS Among patients diagnosed with FSs, we found elevated baseline prevalence of: any psychiatric illness (PR 1.77; 95% CI 1.72-1.82), anxiety disorders (PR 1.92; 1.85-1.99), depression (PR 1.89; 1.83-1.96), psychotropic prescriptions (PR 1.68; 1.64-1.72) and comorbid physical illness (PR 1.28; 1.23-1.32). We found no significant differences in risks for: all-cause mortality (HR 0.99; 0.91-1.09), natural death (HR 0.99; 0.90-1.09), unnatural death (HR 1.00; 0.59-1.72) or suicide (HR 1.68; 0.78-3.63). We did, however, observe a significantly elevated non-fatal self-harm risk: HR 1.83; 1.56-2.15. CONCLUSIONS The absence of elevated premature mortality risk is reassuring. The raised prevalence of mental illness and increased non-fatal self-harm risk indicate a need for enhanced assessment and management of psychopathology associated with fatigue syndromes.
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Affiliation(s)
- Matthew J. Carr
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, ManchesterM13 9PL, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, ManchesterM13 9PL, UK
| | - Darren M. Ashcroft
- NIHR Greater Manchester Patient Safety Translational Research Centre, ManchesterM13 9PL, UK
- Division of Pharmacy and Optometry, Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, ManchesterM13 9PT, UK
| | - Peter D. White
- Wolfson Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Nav Kapur
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, ManchesterM13 9PL, UK
- Greater Manchester Mental Health and Social Care Trust, Manchester, UK
| | - Roger T. Webb
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, ManchesterM13 9PL, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, ManchesterM13 9PL, UK
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Dahl AA, Grotmol KS, Hjermstad MJ, Kiserud CE, Loge JH. Norwegian reference data on the Fatigue Questionnaire and the Patient Health Questionnaire-9 and their interrelationship. Ann Gen Psychiatry 2020; 19:60. [PMID: 33062033 PMCID: PMC7547512 DOI: 10.1186/s12991-020-00311-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/26/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Population-based reference data on frequently used questionnaires are important for comparative purposes. Due to changes in health and lifestyles, such data should be updated every other decade. The objectives of this study were to establish Norwegian population-based reference data on the Fatigue Questionnaire (FQ) and the Patient Health Questionnaire-9 (PHQ-9) on depression, to compare the FQ-scores with our previous reference data from 1996, and to explore the relationship between the scores on these two instruments. METHODS In 2015, a representative sample of 6,012 Norwegians aged 18-80 years was mailed a questionnaire including the FQ and the PHQ-9, and 36% responded. Complete FQ-scores were delivered by 2,041 subjects, and complete PHQ-9 scores by 2,086 subjects. The scores are displayed according to sex and 10-year age groups. RESULTS Few 2015 mean scores of mental, physical, and total fatigue differed significantly from those of 1996, and the same was found for the prevalence rates of chronic fatigue. The exception was a significantly lower prevalence in 2015 of mean fatigue scores and prevalence of chronic fatigue in females ≥ 60 years. The prevalence of major depressive episode (MDE) based on the PHQ-9 sum score cut-off ≥ 10 was 5.9% for males and 9.8% for females, and 2.5% and 3.8% using a DSM-based algorithm with at least five endorsed criteria including either anhedonia or depressed mood. The correlation between the FQ and the PHQ-9 was 0.59, implying 36% shared variance. CONCLUSIONS This study showed considerable interrelationship between the FQ and the PHQ-9 constructs. The reference data show that scores on the FQ have only improved significantly in persons aged 60 or more years between 1996 and 2015. Our prevalence findings of MDE based on the PHQ-9 are in accordance with the findings from other countries. The FQ and the PHQ-9 should be used together in epidemiological and clinical studies.
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Affiliation(s)
- Alv A Dahl
- National Advisory Unit On Late Effects After Cancer Treatment, Oslo University Hospital, 0424 Oslo, Norway.,Faculty of Medicine, University of Oslo, 0316 Oslo, Norway
| | - Kjersti Støen Grotmol
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Marianne Jensen Hjermstad
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Regional Advisory Unit for Palliative Care, Department of Oncology, Oslo University Hospital, 0424 Oslo, Norway
| | - Cecilie Essholt Kiserud
- National Advisory Unit On Late Effects After Cancer Treatment, Oslo University Hospital, 0424 Oslo, Norway
| | - Jon Håvard Loge
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Regional Advisory Unit for Palliative Care, Department of Oncology, Oslo University Hospital, 0424 Oslo, Norway
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Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Comprehensive Review. Diagnostics (Basel) 2019; 9:diagnostics9030091. [PMID: 31394725 PMCID: PMC6787585 DOI: 10.3390/diagnostics9030091] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 12/21/2022] Open
Abstract
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a debilitating chronic disease of unknown aetiology that is recognized by the World Health Organization (WHO) and the United States Center for Disease Control and Prevention (US CDC) as a disorder of the brain. The disease predominantly affects adults, with a peak age of onset of between 20 and 45 years with a female to male ratio of 3:1. Although the clinical features of the disease have been well established within diagnostic criteria, the diagnosis of ME/CFS is still of exclusion, meaning that other medical conditions must be ruled out. The pathophysiological mechanisms are unclear but the neuro-immuno-endocrinological pattern of CFS patients gleaned from various studies indicates that these three pillars may be the key point to understand the complexity of the disease. At the moment, there are no specific pharmacological therapies to treat the disease, but several studies' aims and therapeutic approaches have been described in order to benefit patients' prognosis, symptomatology relief, and the recovery of pre-existing function. This review presents a pathophysiological approach to understanding the essential concepts of ME/CFS, with an emphasis on the population, clinical, and genetic concepts associated with ME/CFS.
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Abstract
PURPOSE Chronic fatigue syndrome (CFS) is a debilitating disease characterized by fatigue, postexertional malaise, cognitive dysfunction, sleep disturbances, and widespread pain. A pilot, online survey was used to determine the common presentations of CFS patients in the emergency department (ED) and attitudes about their encounters. METHODS The anonymous survey was created to score the severity of core CFS symptoms, reasons for going to the ED, and Likert scales to grade attitudes and impressions of care. Open text fields were qualitatively categorized to determine common themes about encounters. RESULTS Fifty-nine percent of respondents with physician-diagnosed CFS (total n=282) had gone to an ED. One-third of ED presentations were consistent with orthostatic intolerance; 42% of participants were dismissed as having psychosomatic complaints. ED staff were not knowledgeable about CFS. Encounters were unfavorable (3.6 on 10-point scale). The remaining 41% of subjects did not go to ED, stating nothing could be done or they would not be taken seriously. CFS subjects can be identified by a CFS questionnaire and the prolonged presence (>6 months) of unremitting fatigue, cognitive, sleep, and postexertional malaise problems. CONCLUSION This is the first investigation of the presentation of CFS in the ED and indicates the importance of orthostatic intolerance as the most frequent acute cause for a visit. The self-report CFS questionnaire may be useful as a screening instrument in the ED. Education of ED staff about modern concepts of CFS is necessary to improve patient and staff satisfaction. Guidance is provided for the diagnosis and treatment of CFS in these challenging encounters.
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Affiliation(s)
- Christian R Timbol
- Division of Rheumatology, Immunology and Allergy, Georgetown University, Washington, DC, USA,
| | - James N Baraniuk
- Division of Rheumatology, Immunology and Allergy, Georgetown University, Washington, DC, USA,
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Lian OS, Robson C. "It´s incredible how much I´ve had to fight." Negotiating medical uncertainty in clinical encounters. Int J Qual Stud Health Well-being 2018; 12:1392219. [PMID: 29063801 PMCID: PMC5654014 DOI: 10.1080/17482631.2017.1392219] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose: Clinical encounters related to medically unexplained physical symptoms (MUPS) are associated with high levels of conflict between patients and doctors. Collaborative difficulties are fused by the medical uncertainty that dominates these consultations. The main aim of this study is to explore the interactional dynamics of clinical encounters riddled by medical uncertainty, as experienced by people living with long-term medically unexplained fatigue in Norway. Method: A qualitative thematic analysis of written texts from 256 study participants. Results: We found that patients experience being met with disbelief, inappropriate psychological explanations, marginalisation of experiences, disrespectful treatment, lack of physical examination and damaging health advice. The main source of their discontent is not the lack of biomedical knowledge, but doctors who fail to communicate acknowledgement of patients’ experiences, knowledge and autonomy. War metaphors are emblematic of how participants describe their medical encounters. The overarching storyline depicts experiences of being caught in a power struggle with doctors and health systems, fused by a lack of common conceptual ground. Conclusion: When physical symptoms cannot be detected, explained and managed by biomedical knowledge and technology, good doctor-patient partnerships are crucial. Without clearly acknowledging patients’ perspectives and capabilities in clinical practice, such partnerships cannot be achieved.
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Affiliation(s)
- Olaug S Lian
- a Department of Community Medicine, Faculty of health sciences , University of Tromsø - The Arctic University of Norway , Tromsø , Norway
| | - Catherine Robson
- a Department of Community Medicine, Faculty of health sciences , University of Tromsø - The Arctic University of Norway , Tromsø , Norway
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Abstract
Myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS) (ME/CFS) is a disabling and debilitating disease of unknown aetiology. It is a heterogeneous disease characterized by various inflammatory, immune, viral, neurological and endocrine symptoms. Several microbiome studies have described alterations in the bacterial component of the microbiome (dysbiosis) consistent with a possible role in disease development. However, in focusing on the bacterial components of the microbiome, these studies have neglected the viral constituent known as the virome. Viruses, particularly those infecting bacteria (bacteriophages), have the potential to alter the function and structure of the microbiome via gene transfer and host lysis. Viral-induced microbiome changes can directly and indirectly influence host health and disease. The contribution of viruses towards disease pathogenesis is therefore an important area for research in ME/CFS. Recent advancements in sequencing technology and bioinformatics now allow more comprehensive and inclusive investigations of human microbiomes. However, as the number of microbiome studies increases, the need for greater consistency in study design and analysis also increases. Comparisons between different ME/CFS microbiome studies are difficult because of differences in patient selection and diagnosis criteria, sample processing, genome sequencing and downstream bioinformatics analysis. It is therefore important that microbiome studies adopt robust, reproducible and consistent study design to enable more reliable and valid comparisons and conclusions to be made between studies. This article provides a comprehensive review of the current evidence supporting microbiome alterations in ME/CFS patients. Additionally, the pitfalls and challenges associated with microbiome studies are discussed.
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Huanan L, Jingui W, Wei Z, Na Z, Xinhua H, Shiquan S, Qing S, Yihao H, Runchen Z, Fei M. Chronic fatigue syndrome treated by the traditional Chinese procedure abdominal tuina: a randomized controlled clinical trial. J TRADIT CHIN MED 2017. [DOI: 10.1016/s0254-6272(18)30046-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Geraghty K, Hann M, Kurtev S. Myalgic encephalomyelitis/chronic fatigue syndrome patients' reports of symptom changes following cognitive behavioural therapy, graded exercise therapy and pacing treatments: Analysis of a primary survey compared with secondary surveys. J Health Psychol 2017; 24:1318-1333. [PMID: 28847166 DOI: 10.1177/1359105317726152] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cognitive behavioural therapy and graded exercise therapy are promoted as evidence-based treatments for myalgic encephalomyelitis/chronic fatigue syndrome. This article explores patients' symptom responses following these treatments versus pacing therapy, an approach favoured by many sufferers. We analyse data from a large cross-sectional patient survey (n = 1428) and compare our findings with those from comparable patient surveys (n = 16,665), using a mix of descriptive statistics and regression analysis modelling. Findings from analysis of primary and secondary surveys suggest that cognitive behavioural therapy is of benefit to a small percentage of patients (8%-35%), graded exercise therapy brings about large negative responses in patients (54%-74%), while pacing is the most favoured treatment with the lowest negative response rate and the highest reported benefit (44%-82%).
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Anderssen J. Because she's worth it. How spa therapists in a Norwegian health resort explain women's need for their services. WOMENS STUDIES INTERNATIONAL FORUM 2017. [DOI: 10.1016/j.wsif.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hansen AH, Lian OS. Experiences of general practitioner continuity among women with chronic fatigue syndrome/myalgic encephalomyelitis: a cross-sectional study. BMC Health Serv Res 2016; 16:650. [PMID: 27842587 PMCID: PMC5109710 DOI: 10.1186/s12913-016-1909-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 11/09/2016] [Indexed: 11/10/2022] Open
Abstract
Background Continuity of care is important for patients with chronic illness in need of coordinated healthcare services from multiple providers. Little is known about how patients with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) experience continuity of GP care. This study explores how women with CFS/ME experience GP care across the three dimensions of continuity: informational, management, and relational continuity. Methods This cross-sectional study uses questionnaire data collected from members of The Norwegian ME Association. Descriptive statistics and logistic regressions were used to estimate experiences of continuity, and associations with age, education, self-rated degree of CFS/ME, duration of the GP relation (GP duration), and number of GP visits for CFS/ME-related issues during the previous year (GP frequency). Results Almost two-thirds of participants reported positive experiences across all three dimensions of GP continuity of care; 64.4% for informational, 64.1% for management, and 77.2% for relational continuity. Lower educational attainment was associated with more negative experiences of informational continuity (primary school only compared to university educated: odds ratio [OR] 0.12, confidence interval [CI] 0.03–0.49, p = 0.003). Compared to participants aged 40–59 years, those aged 60+ years were significantly less likely to have experienced poor (negative) management continuity (OR 0.25, CI 0.09–0.76, p = 0.014). A GP relationship of three or more years was associated with positive experiences of relational continuity (OR 2.32, CI 1.09–4.95, p = 0.030). Compared to those with moderate CFS/ME, those who graded their CFS/ME as severe or very severe were significantly more likely to have negative experiences of relational continuity (OR 0.38, CI 0.14–0.99, p = 0.047). Conclusions A large proportion of participants experienced all three aspects of continuity of GP care (especially the relational dimension) positively. Informational and management continuity scores were moderately lower. Our results suggest greater emphasis on information giving, feedback, and better coordination of care to be good strategies for practice improvement for this patient group. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1909-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anne Helen Hansen
- Faculty of Health Sciences, Department of Community Medicine, University of Tromsø - The Arctic University of Norway, 9037, Tromsø, Norway. .,University Hospital of North Norway, PO box 35, 9038, Tromsø, Norway.
| | - Olaug S Lian
- Faculty of Health Sciences, Department of Community Medicine, University of Tromsø - The Arctic University of Norway, 9037, Tromsø, Norway
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Hansen AH, Lian OS. How do women with chronic fatigue syndrome/myalgic encephalomyelitis rate quality and coordination of healthcare services? A cross-sectional study. BMJ Open 2016; 6:e010277. [PMID: 27044578 PMCID: PMC4823449 DOI: 10.1136/bmjopen-2015-010277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To test the association between self-rated health and self-rated degree of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME), and CFS/ME patients' assessment of quality of primary care, specialist care and coordination of care. DESIGN Cross-sectional study. SETTING Self-reported questionnaire data from women members of The Norwegian ME Association obtained in 2013. PARTICIPANTS 431 women with CFS/ME aged 16-73 years. MAIN OUTCOME MEASURE The participants' assessment of quality in primary care, specialist care and in coordination of care (good/very good or poor/very poor). Main explanatory variables: self-rated health and self-rated degree of CFS/ME. RESULTS Quality of care was rated poor by 60.6% in primary care, by 47.7% in specialist care, and by 71.2% regarding coordination of care. Poorer self-rated health increased the probability of rating quality in primary care poor, particularly among women 40 years and over (OR 2.38, 95% CI 1.63 to 3.49), women with university education (OR 2.57, CI 1.68 to 3.94), and owing to less frequent general practitioner (GP) visits (OR 2.46, CI 1.60 to 3.78). Poorer self-rated health increased the probability of rating quality poor in specialist care (OR 1.38, CI 1.05 to 1.82), but not in coordination of care. A more severe CFS/ME was associated with a higher probability of rating quality in primary care poor (OR 0.61, CI 0.38 to 0.93). Frequent visitors and those with a long GP relationship were less likely to report primary care quality as poor. CONCLUSIONS A large proportion of women with CFS/ME rated quality of care poor/very poor in primary care, specialist care and in coordination of care. The dissatisfaction was higher for primary care than for specialist care. Overall, poorer self-rated health and a more severe CFS/ME were associated with lower quality scores in primary and specialist care, but not in coordination of care. Healthcare services, as assessed by women with CFS/ME, do have a large potential for improvement.
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Affiliation(s)
- Anne Helen Hansen
- Faculty of Health Sciences, Department of Community Medicine, UiT The Arctic University of Norway and Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway
| | - Olaug S Lian
- Faculty of Health Sciences, Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Russell L, Broderick G, Taylor R, Fernandes H, Harvey J, Barnes Z, Smylie A, Collado F, Balbin EG, Katz BZ, Klimas NG, Fletcher MA. Illness progression in chronic fatigue syndrome: a shifting immune baseline. BMC Immunol 2016; 17:3. [PMID: 26965484 PMCID: PMC4785654 DOI: 10.1186/s12865-016-0142-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 02/29/2016] [Indexed: 01/04/2023] Open
Abstract
Background Validation of biomarkers for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) across data sets has proven disappointing. As immune signature may be affected by many factors, our objective was to explore the shift in discriminatory cytokines across ME/CFS subjects separated by duration of illness. Methods Cytokine expression collected at rest across multiple studies for female ME/CFS subjects (i) 18 years or younger, ill for 2 years or less (n = 18), (ii) 18–50 years of age, ill for 7 years (n = 22), and (iii) age 50 years or older (n = 28), ill for 11 years on average. Control subjects were matched for age and body mass index (BMI). Data describing the levels of 16 cytokines using a chemiluminescent assay was used to support the identification of separate linear classification models for each subgroup. In order to isolate the effects of duration of illness alone, cytokines that changed significantly with age in the healthy control subjects were excluded a priori. Results Optimal selection of cytokines in each group resulted in subsets of IL-1α, 6, 8, 15 and TNFα. Common to any 2 of 3 groups were IL-1α, 6 and 8. Setting these 3 markers as a triple screen and adjusting their contribution according to illness duration sub-groups produced ME/CFS classification accuracies of 75–88 %. The contribution of IL-1α, higher in recently ill adolescent ME/CFS subjects was progressively less important with duration. While high levels of IL-8 screened positive for ME/CFS in the recently afflicted, the opposite was true for subjects ill for more than 2 years. Similarly, while low levels of IL-6 suggested early ME/CFS, the reverse was true in subjects over 18 years of age ill for more than 2 years. Conclusions These preliminary results suggest that IL-1α, 6 and 8 adjusted for illness duration may serve as robust biomarkers, independent of age, in screening for ME/CFS. Electronic supplementary material The online version of this article (doi:10.1186/s12865-016-0142-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lindsey Russell
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Gordon Broderick
- Department of Medicine, University of Alberta, Edmonton, AB, Canada. .,Miami Veterans Affairs Medical Center, Miami, FL, USA. .,Institute for Neuro-immune Medicine, Nova Southeastern University, Suite 3440 University Park Plaza, 3424 South University Drive, Fort Lauderdale, FL, 33328, USA.
| | - Renee Taylor
- Department of Occupational Therapy, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Jeanna Harvey
- Department of Medicine, University of Miami, Miami, FL, USA.,Miami Veterans Affairs Medical Center, Miami, FL, USA
| | - Zachary Barnes
- Department of Medicine, University of Miami, Miami, FL, USA.,Miami Veterans Affairs Medical Center, Miami, FL, USA.,Institute for Neuro-immune Medicine, Nova Southeastern University, Suite 3440 University Park Plaza, 3424 South University Drive, Fort Lauderdale, FL, 33328, USA
| | - AnneLiese Smylie
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Fanny Collado
- Miami Veterans Affairs Medical Center, Miami, FL, USA
| | | | - Ben Z Katz
- Division of Infectious Diseases, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Nancy G Klimas
- Miami Veterans Affairs Medical Center, Miami, FL, USA.,Institute for Neuro-immune Medicine, Nova Southeastern University, Suite 3440 University Park Plaza, 3424 South University Drive, Fort Lauderdale, FL, 33328, USA
| | - Mary Ann Fletcher
- Miami Veterans Affairs Medical Center, Miami, FL, USA.,Institute for Neuro-immune Medicine, Nova Southeastern University, Suite 3440 University Park Plaza, 3424 South University Drive, Fort Lauderdale, FL, 33328, USA
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Egeland T, Angelsen A, Haug R, Henriksen JO, Lea TE, Saugstad OD. What exactly is myalgic encephalomyelitis? TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2015; 135:1756-9. [PMID: 26486672 DOI: 10.4045/tidsskr.15.0089] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Lian OS, Bondevik H. Medical constructions of long-term exhaustion, past and present. SOCIOLOGY OF HEALTH & ILLNESS 2015; 37:920-935. [PMID: 25912053 DOI: 10.1111/1467-9566.12249] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Culture and history affect the ways in which medical knowledge is shaped, sustained and changed. The less knowledge we have, the larger the space for the cultural imprint becomes. Based on these assumptions, we ask: how have medical constructions of long-term exhaustion changed over time, and how are changing constructions related to societal change? To discuss these questions we conducted a comparative study of medical texts from two historical periods: 1860-1930 and 1970-2013. Our data are limited to two diagnoses: neurasthenia and encephalomyelitis. After comparing the two periods by identifying diverging and converging aspects, we interpreted observed continuities and interruptions in relation to historical developments. We found that in the medical literature, long-term exhaustion became transformed from a somatic ailment bred by modern civilisation to a self-inflicted psychiatric ailment. At the same time, it changed from being a male-connoted high-status condition to a female-connoted low-status condition. We interpret these changes as contingent upon culturally available modes of interpretations. Medical knowledge thereby becomes infused with cultural norms and values which give them a distinct cultural bias. The historical controversies surrounding this medically contested condition neatly display the socially contingent factors that govern the social construction of medical knowledge.
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Affiliation(s)
- Olaug S Lian
- Department of Community Medicine, University of Tromsø - The Arctic University of Norway, Norway
| | - Hilde Bondevik
- Institute of Health and Society, University of Oslo, Norway
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Lian OS, Hansen AH. Factors facilitating patient satisfaction among women with medically unexplained long-term fatigue: A relational perspective. Health (London) 2015; 20:308-26. [DOI: 10.1177/1363459315583158] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Bodily conditions that are difficult to identify, explain and treat with the aid of medical knowledge and technology appear to be particularly challenging to medical encounters. Patients are often dissatisfied with the help they receive, and they often experience that their medical needs are not met. To explore factors facilitating patient satisfaction among patients with a medically unexplained condition, we ask: what is the importance of individual versus relational factors in facilitating patient satisfaction in clinical encounters between general practitioners (GPs) and women with medically unexplained long-term fatigue? We approach this question through a statistical analysis of survey data collected from a net sample of 431 women recruited through a patient organisation for people suffering from myalgic encephalomyelitis in 2013. Participants were asked about their experiences with general practitioners in the Norwegian national health system in two different phases: shortly after illness onset, and current regular general practitioner last 12 months. The questions evolved around themes concerning shared understanding and decision making, being taken seriously, being paid due respect and being treated as an equal partner. Through descriptive statistics and multivariable logistic regression analyses, we explored how their experiences were related to individual and relational factors, respectively. Free-text comments from the questionnaires were used while interpreting the results. The analysis illuminates that relational aspects in medical encounters between GPs and ME patients, especially continuity, congruence in doctor–patient views and being seen by a specialist, are important catalysts of patient satisfaction. The probability of being satisfied with the initial investigation was more than six times higher in women who were referred to specialists, compared to those who were not. We conclude that continuity of care and experiences of being in a partnership that operates on a common ground – a shared understanding of the patient’s illness – foster patient satisfaction among women with medically unexplained long-term fatigue.
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Affiliation(s)
- Olaug S Lian
- University of Tromsø – The Arctic University of Norway, Norway
| | - Anne Helen Hansen
- University of Tromsø – The Arctic University of Norway, Norway; University Hospital of North Norway, Norway
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Nacul L, O’Donovan DG, Lacerda EM, Gveric D, Goldring K, Hall A, Bowman E, Pheby D. Considerations in establishing a post-mortem brain and tissue bank for the study of myalgic encephalomyelitis/chronic fatigue syndrome: a proposed protocol. BMC Res Notes 2014; 7:370. [PMID: 24938650 PMCID: PMC4076507 DOI: 10.1186/1756-0500-7-370] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 06/02/2014] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Our aim, having previously investigated through a qualitative study involving extensive discussions with experts and patients the issues involved in establishing and maintaining a disease specific brain and tissue bank for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), was to develop a protocol for a UK ME/CFS repository of high quality human tissue from well characterised subjects with ME/CFS and controls suitable for a broad range of research applications. This would involve a specific donor program coupled with rapid tissue collection and processing, supplemented by comprehensive prospectively collected clinical, laboratory and self-assessment data from cases and controls. FINDINGS We reviewed the operations of existing tissue banks from published literature and from their internal protocols and standard operating procedures (SOPs). On this basis, we developed the protocol presented here, which was designed to meet high technical and ethical standards and legal requirements and was based on recommendations of the MRC UK Brain Banks Network. The facility would be most efficient and cost-effective if incorporated into an existing tissue bank. Tissue collection would be rapid and follow robust protocols to ensure preservation sufficient for a wide range of research uses. A central tissue bank would have resources both for wide-scale donor recruitment and rapid response to donor death for prompt harvesting and processing of tissue. CONCLUSION An ME/CFS brain and tissue bank could be established using this protocol. Success would depend on careful consideration of logistic, technical, legal and ethical issues, continuous consultation with patients and the donor population, and a sustainable model of funding ideally involving research councils, health services, and patient charities. This initiative could revolutionise the understanding of this still poorly-understood disease and enhance development of diagnostic biomarkers and treatments.
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Affiliation(s)
- Luis Nacul
- London School of Hygiene & Tropical Medicine, ITD/CRD/International Centre for Evidence in Disability, K/490, Keppel Street, WC1E 7HT London, UK
| | - Dominic G O’Donovan
- Department of Histopathology, Box 235 Level 5 John Bonnett Clincal Laboratories, Addenbrooke’s Hospital, Hills Road, CB1 0QQ Cambridge, UK
| | - Eliana M Lacerda
- London School of Hygiene & Tropical Medicine, ITD/CRD/International Centre for Evidence in Disability, K/490, Keppel Street, WC1E 7HT London, UK
| | - Djordje Gveric
- The UK Multiple Sclerosis and Parkinson’s Disease Tissue Banks, Hammersmith Campus, Imperial College, 160 Du Cane Road, W12 0NN London, UK
| | - Kirstin Goldring
- UCL-RFH BioBank, Royal Free Hospital, 1st Floor, Rowland Hill Street, NW3 2PF Hampstead, UK
| | - Alison Hall
- PHG Foundation, 2 Wort’s Causeway, Cambridge CB1 8RN, UK
| | - Erinna Bowman
- London School of Hygiene & Tropical Medicine, ITD/CRD/International Centre for Evidence in Disability, K/490, Keppel Street, WC1E 7HT London, UK
| | - Derek Pheby
- Faculty of Health and Society, Buckinghamshire New University, Uxbridge Campus, 106, Oxford Road, Uxbridge, Middlesex UB8 1NA, USA
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Differing leukocyte gene expression profiles associated with fatigue in patients with prostate cancer versus chronic fatigue syndrome. Psychoneuroendocrinology 2013; 38:2983-95. [PMID: 24054763 PMCID: PMC3848711 DOI: 10.1016/j.psyneuen.2013.08.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 08/22/2013] [Accepted: 08/27/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Androgen deprivation therapy (ADT) often worsens fatigue in patients with prostate cancer, producing symptoms similar to chronic fatigue syndrome (CFS). Comparing expression (mRNA) of many fatigue-related genes in patients with ADT-treated prostate cancer versus with CFS versus healthy controls, and correlating mRNA with fatigue severity may clarify the differing pathways underlying fatigue in these conditions. METHODS Quantitative real-time PCR was performed on leukocytes from 30 fatigued, ADT-treated prostate cancer patients (PCF), 39 patients with CFS and 22 controls aged 40-79, together with ratings of fatigue and pain severity. 46 genes from these pathways were included: (1) adrenergic/monoamine/neuropeptides, (2) immune, (3) metabolite-detecting, (4) mitochondrial/energy, (5) transcription factors. RESULTS PCF patients showed higher expression than controls or CFS of 2 immune transcription genes (NR3C1 and TLR4), chemokine CXCR4, and mitochondrial gene SOD2. They showed lower expression of 2 vasodilation-related genes (ADRB2 and VIPR2), 2 cytokines (TNF and LTA), and 2 metabolite-detecting receptors (ASIC3 and P2RX7). CFS patients showed higher P2RX7 and lower HSPA2 versus controls and PCF. Correlations with fatigue severity were similar in PCF and CFS for only DBI, the GABA-A receptor modulator (r=-0.50, p<0.005 and r=-0.34, p<0.05). Purinergic P2RY1 was correlated only with PCF fatigue and pain severity (r=+0.43 and +0.59, p=0.025 and p=0.001). CONCLUSIONS PCF patients differed from controls and CFS in mean expression of 10 genes from all 5 pathways. Correlations with fatigue severity implicated DBI for both patient groups and P2RY1 for PCF only. These pathways may provide new targets for interventions to reduce fatigue.
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Morris G, Maes M. Myalgic encephalomyelitis/chronic fatigue syndrome and encephalomyelitis disseminata/multiple sclerosis show remarkable levels of similarity in phenomenology and neuroimmune characteristics. BMC Med 2013; 11:205. [PMID: 24229326 PMCID: PMC3847236 DOI: 10.1186/1741-7015-11-205] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 08/15/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND 'Encephalomyelitis disseminata' (multiple sclerosis) and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) are both classified as diseases of the central nervous system by the World Health Organization. This review aims to compare the phenomenological and neuroimmune characteristics of MS with those of ME/CFS. DISCUSSION There are remarkable phenomenological and neuroimmune overlaps between both disorders. Patients with ME/CFS and MS both experience severe levels of disabling fatigue and a worsening of symptoms following exercise and resort to energy conservation strategies in an attempt to meet the energy demands of day-to-day living. Debilitating autonomic symptoms, diminished cardiac responses to exercise, orthostatic intolerance and postural hypotension are experienced by patients with both illnesses. Both disorders show a relapsing-remitting or progressive course, while infections and psychosocial stress play a large part in worsening of fatigue symptoms. Activated immunoinflammatory, oxidative and nitrosative (O+NS) pathways and autoimmunity occur in both illnesses. The consequences of O+NS damage to self-epitopes is evidenced by the almost bewildering and almost identical array of autoantibodies formed against damaged epitopes seen in both illnesses. Mitochondrial dysfunctions, including lowered levels of ATP, decreased phosphocreatine synthesis and impaired oxidative phosphorylation, are heavily involved in the pathophysiology of both MS and ME/CFS. The findings produced by neuroimaging techniques are quite similar in both illnesses and show decreased cerebral blood flow, atrophy, gray matter reduction, white matter hyperintensities, increased cerebral lactate and choline signaling and lowered acetyl-aspartate levels. SUMMARY This review shows that there are neuroimmune similarities between MS and ME/CFS. This further substantiates the view that ME/CFS is a neuroimmune illness and that patients with MS are immunologically primed to develop symptoms of ME/CFS.
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Affiliation(s)
- Gerwyn Morris
- Tir Na Nog, Pembrey, Llanelli, UK
- Department of Psychiatry, Chulalongkorn University, Bangkok, Thailand
| | - Michael Maes
- Department of Psychiatry, Chulalongkorn University, Bangkok, Thailand
- Department of Psychiatry, Deakin University, Geelong, Australia
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Brenu EW, Hardcastle SL, Atkinson GM, van Driel ML, Kreijkamp-Kaspers S, Ashton KJ, Staines DR, Marshall-Gradisnik SM. Natural killer cells in patients with severe chronic fatigue syndrome. AUTOIMMUNITY HIGHLIGHTS 2013; 4:69-80. [PMID: 26000145 PMCID: PMC4389023 DOI: 10.1007/s13317-013-0051-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 03/06/2013] [Indexed: 02/06/2023]
Abstract
Maintenance of health and physiological homeostasis is a synergistic process involving tight regulation of proteins, transcription factors and other molecular processes. The immune system consists of innate and adaptive immune cells that are required to sustain immunity. The presence of pathogens and tumour cells activates innate immune cells, in particular Natural Killer (NK) cells. Stochastic expression of NK receptors activates either inhibitory or activating signals and results in cytokine production and activation of pathways that result in apoptosis of target cells. Thus, NK cells are a necessary component of the immunological process and aberrations in their functional processes, including equivocal levels of NK cells and cytotoxic activity pre-empts recurrent viral infections, autoimmune diseases and altered inflammatory responses. NK cells are implicated in a number of diseases including chronic fatigue syndrome (CFS). The purpose of this review is to highlight the different profiles of NK cells reported in CFS patients and to determine the extent of NK immune dysfunction in subtypes of CFS patients based on severity in symptoms.
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Affiliation(s)
- E. W. Brenu
- Griffith Health Institute, School of Medical Science, Griffith University, Gold Coast, QLD Australia
- The National Centre for Neuroimmunology and Emerging Diseases, Griffith University, Gold Coast, QLD Australia
- Immunology Research Group, Centre for Medicine and Oral Health, Griffith University, GH1, Room 7.59, Southport, QLD 4215 Australia
| | - S. L. Hardcastle
- Griffith Health Institute, School of Medical Science, Griffith University, Gold Coast, QLD Australia
- The National Centre for Neuroimmunology and Emerging Diseases, Griffith University, Gold Coast, QLD Australia
| | - G. M. Atkinson
- Griffith Health Institute, School of Medical Science, Griffith University, Gold Coast, QLD Australia
- The National Centre for Neuroimmunology and Emerging Diseases, Griffith University, Gold Coast, QLD Australia
| | - M. L. van Driel
- Queensland Health, Gold Coast Public Health Unit, Robina, Gold Coast, QLD Australia
| | | | - K. J. Ashton
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD Australia
| | - D. R. Staines
- The National Centre for Neuroimmunology and Emerging Diseases, Griffith University, Gold Coast, QLD Australia
- Queensland Health, Gold Coast Public Health Unit, Robina, Gold Coast, QLD Australia
| | - S. M. Marshall-Gradisnik
- Griffith Health Institute, School of Medical Science, Griffith University, Gold Coast, QLD Australia
- The National Centre for Neuroimmunology and Emerging Diseases, Griffith University, Gold Coast, QLD Australia
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Lee LL, Lin L, Bell DS, Levine S, Hanson MR. Sensitivity of PCR assays for murine gammaretroviruses and mouse contamination in human blood samples. PLoS One 2012; 7:e37482. [PMID: 22629404 PMCID: PMC3357399 DOI: 10.1371/journal.pone.0037482] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Accepted: 04/24/2012] [Indexed: 11/19/2022] Open
Abstract
Gammaretroviruses related to murine leukemia virus (MLV) have variously been reported to be present or absent in blood from chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) patients and healthy controls. Using subjects from New York State, we have investigated by PCR methods whether MLV-related sequences can be identified in nucleic acids isolated from whole blood or from peripheral blood mononuclear cells (PBMCs) or following PBMC culture. We have also passaged the prostate cancer cell line LNCaP following incubation with plasma from patients and controls and assayed nucleic acids for viral sequences. We have used 15 sets of primers that can effectively amplify conserved regions of murine endogenous and exogenous retrovirus sequences. We demonstrate that our PCR assays for MLV-related gag sequences and for mouse DNA contamination are extremely sensitive. While we have identified MLV-like gag sequences following PCR on human DNA preparations, we are unable to conclude that these sequences originated in the blood samples.
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Affiliation(s)
- Li Ling Lee
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, New York, United States of America
| | - Lin Lin
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, New York, United States of America
| | - David S. Bell
- Department of Pediatrics, State University of New York, Buffalo, New York, United States of America
| | - Susan Levine
- Private Practice, New York, New York, United States of America
| | - Maureen R. Hanson
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, New York, United States of America
- * E-mail:
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Karlson R. En evolusjonær forståelse av kronisk utmattelsessyndrom. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2012; 132:400-1. [DOI: 10.4045/tidsskr.11.1335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Benefit from B-lymphocyte depletion using the anti-CD20 antibody rituximab in chronic fatigue syndrome. A double-blind and placebo-controlled study. PLoS One 2011; 6:e26358. [PMID: 22039471 PMCID: PMC3198463 DOI: 10.1371/journal.pone.0026358] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 09/25/2011] [Indexed: 11/19/2022] Open
Abstract
Background Chronic fatigue syndrome (CFS) is a disease of unknown aetiology. Major CFS symptom relief during cancer chemotherapy in a patient with synchronous CFS and lymphoma spurred a pilot study of B-lymphocyte depletion using the anti-CD20 antibody Rituximab, which demonstrated significant clinical response in three CFS patients. Methods and Findings In this double-blind, placebo-controlled phase II study (NCT00848692), 30 CFS patients were randomised to either Rituximab 500 mg/m2 or saline, given twice two weeks apart, with follow-up for 12 months. Xenotropic murine leukemia virus-related virus (XMRV) was not detected in any of the patients. The responses generally affected all CFS symptoms. Major or moderate overall response, defined as lasting improvements in self-reported Fatigue score during follow-up, was seen in 10 out of 15 patients (67%) in the Rituximab group and in two out of 15 patients (13%) in the Placebo group (p = 0.003). Mean response duration within the follow-up period for the 10 responders to Rituximab was 25 weeks (range 8–44). Four Rituximab patients had clinical response durations past the study period. General linear models for repeated measures of Fatigue scores during follow-up showed a significant interaction between time and intervention group (p = 0.018 for self-reported, and p = 0.024 for physician-assessed), with differences between the Rituximab and Placebo groups between 6–10 months after intervention. The primary end-point, defined as effect on self-reported Fatigue score 3 months after intervention, was negative. There were no serious adverse events. Two patients in the Rituximab group with pre-existing psoriasis experienced moderate psoriasis worsening. Conclusion The delayed responses starting from 2–7 months after Rituximab treatment, in spite of rapid B-cell depletion, suggests that CFS is an autoimmune disease and may be consistent with the gradual elimination of autoantibodies preceding clinical responses. The present findings will impact future research efforts in CFS. Trial registration ClinicalTrials.gov NCT00848692
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Sepede G, Racciatti D, Gorgoretti V, Nacci M, Pizzigallo E, Onofrj M, Di Giannantonio M, Niolu C, Salerno R, Gambi F. Psychophysical Distress and Alexithymic Traits in Chronic Fatigue Syndrome with and without Comorbid Depression. Int J Immunopathol Pharmacol 2011; 24:1017-25. [DOI: 10.1177/039463201102400419] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Patients with Chronic Fatigue Syndrome (CFS) often report a comorbid depressive disorder. Comorbid depression may negatively influence the long-term outcome of CFS therefore it must be correctly diagnosed and treated. The aim of the present study is to provide a clinical and psychometric assessment of CFS patients with and without depressive features. A comparative analysis between 57 CFS subjects (CDC, 1994), 17 of whom with a comorbid depression, and 55 matched healthy volunteers was assessed to evaluate the presence of any psychophysical distress and alexithymic traits, by means of Symptom Checklist-90-R (SCL-90R) and Toronto Alexithymia Scale (TAS-20). The severity of fatigue was also assessed in all CFS patients using the Fatigue Impact Scale (FIS). With regard to psychiatric comorbidity, the SCL-90R scores showed higher levels of somatic complaints in CFS patients than in healthy subjects, whereas augmented depressive and obsessive-compulsive symptoms were observed only in the depressed CFS subgroup. When comparing the TAS-20 scores, we observed a selective impairment in the capacity to identify feelings and emotions, as measured by the Difficulty in Identifying Feelings subscale (DIF), non-depressed CFS patients showing an intermediate score between depressed CFS and healthy controls. Finally, in terms of FIS scores, a statistical trend versus a higher fatigue severity in depressed CFS patients, with respect to non-depressed ones, was observed. In conclusion, comorbid depression in CFS significantly increased the level of psychophysical distress and the severity of alexithymic traits. These findings suggest an urgent need to address and treat depressive disorders in the clinical care of CFS cases, to improve social functioning and quality of life in such patients.
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Affiliation(s)
- G. Sepede
- Department of Neuroscience and Imaging, “G. d'Annunzio” University, Chieti
| | - D. Racciatti
- Clinic of Infectious Diseases, Department of Medicine and Aging, “G. d'Annunzio” University, Chieti
| | - V. Gorgoretti
- Clinic of Infectious Diseases, Department of Medicine and Aging, “G. d'Annunzio” University, Chieti
| | - M. Nacci
- Department of Mental Health, National Health Trust, Taranto
| | - E. Pizzigallo
- Clinic of Infectious Diseases, Department of Medicine and Aging, “G. d'Annunzio” University, Chieti
| | - M. Onofrj
- Department of Neuroscience and Imaging, “G. d'Annunzio” University, Chieti
| | - M. Di Giannantonio
- Department of Neuroscience and Imaging, “G. d'Annunzio” University, Chieti
- Center of Mental Health, National Health Trust, Chieti, Italy
| | - C. Niolu
- Psychiatric Unit, Tor Vergata University, Rome, Italy
| | - R.M. Salerno
- Department of Neuroscience and Imaging, “G. d'Annunzio” University, Chieti
| | - F. Gambi
- Department of Neuroscience and Imaging, “G. d'Annunzio” University, Chieti
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