The neuroendocrinology of chronic fatigue syndrome

Effects of acupuncture on hypothalamic-pituitary-adrenal axis: Current status and future perspectives

The hypothalamic-pituitary-adrenal (HPA) axis is a critical component of the neuroendocrine system, playing a central role in regulating the body's stress response and modulating various physiological processes. Dysregulation of HPA axis function disrupts the neuroendocrine equilibrium, resulting in impaired physiological functions. Acupuncture is recognized as a non-pharmacological type of therapy which has been confirmed to play an important role in modulating the HPA axis and thus favorably targets diseases with abnormal activation of the HPA axis. With numerous studies reporting the promising efficacy of acupuncture for neuroendocrine disorders, a comprehensive review in terms of the underlying molecular mechanism for acupuncture, especially in regulating the HPA axis, is currently in need. This review fills the need and summarizes recent breakthroughs, from the basic principles and the pathological changes of HPA axis dysfunction, to the molecular mechanisms by which acupuncture regulates the HPA axis. These mechanisms include the modulation of multiple neurotransmitters and their receptors, neuropeptides and their receptors, and microRNAs in the paraventricular nucleus, hippocampus, amygdala and pituitary gland, which alleviate the hyperfunctioning of the HPA axis. This review comprehensively summarizes the mechanism of acupuncture in regulating HPA axis dysfunction for the first time, providing new targets and prospects for further exploration of acupuncture. Please cite this article as: Zheng JY, Zhu J, Wang Y, Tian ZZ. Effects of acupuncture on hypothalamic-pituitary-adrenal axis: Current status and future perspectives. J Integr Med. 2024; 22(4): 446-459.

The gastrointestinal microbiota in the development of ME/CFS: a critical view and potential perspectives

Like other infections, a SARS-CoV-2 infection can also trigger Post-Acute Infection Syndromes (PAIS), which often progress into myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). ME/CFS, characterized by post-exercise malaise (PEM), is a severe multisystemic disease for which specific diagnostic markers or therapeutic concepts have not been established. Despite numerous indications of post-infectious neurological, immunological, endocrinal, and metabolic deviations, the exact causes and pathophysiology remain unclear. To date, there is a paucity of data, that changes in the composition and function of the gastrointestinal microbiota have emerged as a potential influencing variable associated with immunological and inflammatory pathways, shifts in ME/CFS. It is postulated that this dysbiosis may lead to intestinal barrier dysfunction, translocation of microbial components with increased oxidative stress, and the development or progression of ME/CFS. In this review, we detailed discuss the findings regarding alterations in the gastrointestinal microbiota and its microbial mediators in ME/CFS. When viewed critically, there is currently no evidence indicating causality between changes in the microbiota and the development of ME/CFS. Most studies describe associations within poorly defined patient populations, often combining various clinical presentations, such as irritable bowel syndrome and fatigue associated with ME/CFS. Nevertheless, drawing on analogies with other gastrointestinal diseases, there is potential to develop strategies aimed at modulating the gut microbiota and/or its metabolites as potential treatments for ME/CFS and other PAIS. These strategies should be further investigated in clinical trials.

A prospective study on endocrine function in patients with long-COVID symptoms

OBJECTIVE

To investigate hormonal status in patients with long-COVID and explore the interrelationship between hormone levels and long-COVID symptoms.

DESIGN

Prospective observational study.

PARTICIPANTS

Patients who visited our long-COVID outpatients' clinic due to long-COVID symptoms from February 2021 to December 2022.

MEASUREMENTS

Total triiodothyronine, free thyroxine, thyrotropin, thyroglobulin, anti-thyroperoxidase, and antithyroglobulin autoantibodies were measured for thyroid assessment. Other hormones measured were growth hormone, insulin-like growth factor 1 (IGF-1), adrenocorticotropic hormone (ACTH), serum cortisol, dehydroepiandrosterone sulfate (DHEA-S), total testosterone, plasma insulin, and C-peptide. Blood glucose and glycosylated hemoglobin were also measured. To assess adrenal reserve, an ACTH stimulation test was performed. The fatigue assessment scale (FAS) was used to evaluate fatigue severity.

RESULTS

Eighty-four adult patients were included. Overall, 40.5% of the patients had at least one endocrine disorder. These included prediabetes (21.4%), low DHEA-S (21.4%), subclinical hypothyroidism (3.6%), non-specific thyroid function abnormality (7.1%), thyroid autoimmunity (7.1%), low testosterone in males (6.6%), and low IGF-1 (3.6%). All patients had normal adrenal reserve. Long-COVID-19 symptoms were present in all patients and the most commonly reported symptom was fatigue (89.3%). The FAS score was higher than normal (≥ 22) in 42.8% of patients. There were no associations between patients' symptoms and hormone levels. Diabetic patients reported confusion (p = 0.020) and hair loss (p = 0.040) more often than non-diabetics.

CONCLUSIONS

The evaluation of endocrine function 3 months after a positive SARS-CoV2 test revealed only subclinical syndromes. The vast majority of patients reported mainly fatigue, among other symptoms, which were unrelated, however, to endocrine function.

Neuron-Microglia Interaction is Involved in Anti-inflammatory Response by Vagus Nerve Stimulation in the Prefrontal Cortex of Rats Injected with Polyinosinic:Polycytidylic Acid

Injection of polyinosinic:polycytidylic acid (poly(I:C)) into experimental animals induces neuroimmunological responses and thus has been used for the study of neurological disorders such as anxiety, depression, and chronic fatigue. Here, we investigated the effects of vagus nerve stimulation (VNS) on poly(I:C)-induced neuroinflammation and associated behavioral consequences in rats. The microglia in the prefrontal cortex (PFC) displayed the activated form of morphology in poly(I:C)-injected rats and changed to a normal shape after acute VNS (aVNS). Production of phospho-NF-κB, phospho-IκB, IL-1β, and cleaved caspase 3 was elevated by poly(I:C) and downregulated by aVNS. In contrast, phospho-Akt levels were decreased by poly(I:C) and increased by aVNS. Neuronal production of fractalkine (CX3CL1) in the PFC was markedly reduced by poly(I:C), but recovered by aVNS. Fractalkine interaction with its receptor CX3CR1 was highly elevated by VNS. We further demonstrated that the pharmacological blockade of CX3CR1 activity counteracted the production of IL-1β, phospho-Akt, and cleaved form of caspase 3 that was modulated by VNS, suggesting the anti-inflammatory effects of fractalkine-CX3CR1 signaling as a mediator of neuron-microglia interaction. Behavioral assessments of pain and temperature sensations by von Frey and hot/cold plate tests showed significant improvement by chronic VNS (cVNS) and forced swimming and marble burying tests revealed that the depressive-like behaviors caused by poly(I:C) injection were rescued by cVNS. We also found that the recognition memory which was impaired by poly(I:C) administration was improved by cVNS. This study suggests that VNS may play a role in regulating neuroinflammation and somatosensory and cognitive functions in poly(I:C)-injected animals.

Overview of the Current Pathophysiology of Fatigue in Multiple Sclerosis, Its Diagnosis and Treatment Options - Review Article

Fatigue is a common, debilitating and often underestimated symptom in patients with multiple sclerosis (MS). The exact pathophysiological mechanism of fatigue in MS is still unknown. However, there are many theories involving different immunological, metabolic and inflammatory mechanisms of fatigue. Owing to the subjective nature of this symptom, its diagnosis is still very limited and is still based only on diagnostic questionnaires. Although several therapeutic agents have been used in the past to try to influence fatigue in MS patients, no single effective approach for the treatment of fatigue has yet been found. This review article aims to provide the reader with information on the current theories on the origin and mechanism of fatigue in MS, as well as diagnostic procedures and, finally, current therapeutic strategies for the management of fatigue in MS patients.

Digital Danger in Our Pockets: Effect of Smartphone Overuse on Mental Fatigue and Cognitive Flexibility

ABSTRACT

Smartphones have become essential to life in Western society. This situation reached its peak, especially during the pandemic period. The possibility that smartphone use has negative impact on brain activity has attracted increasing interest among researchers. Medical faculty students were contacted via e-mail and invited to participate in the study. Participants completed the Smartphone Addiction Scale (SAS), the Mental Fatigue Scale (MFS), and the Cognitive Flexibility Inventory (CFI). The total SAS scores of participants with mental fatigue were significantly higher than those of participants without mental fatigue (p < 0.001). In the smartphone addiction tendency group, the total MFS scores were significantly higher, and the total CFI scores were significantly lower than the scores of the control group (p < 0.001 for both). In the logistic regression analysis, the total SAS score was associated with the development of mental fatigue (B coefficient, 0.031, p < 0.001). This study identified potential relationships between smartphone addiction, mental fatigue, and cognitive flexibility. We suggest that smartphone overuse may be an independent risk factor for the development of mental fatigue.

A serial mediation model of social media addiction and college students' academic engagement: the role of sleep quality and fatigue

BACKGROUND

It has been documented that social media addiction (SMA) has a detrimental effect on college students' academic engagement. However, the mechanisms underlying this association are not well understood. This study aimed to determine the serial mediation effects of sleep quality and fatigue on the relationship between SMA and academic engagement among college students.

METHODS

A cross-sectional survey was conducted with 2661 college students (43.3% males, mean age = 19.97 years). The participants completed the Bergen Social Media Addiction Scale, the Utrecht Student Work Engagement Scale for Students, the Pittsburgh Sleep Quality Index, and the Fatigue Assessment Scale. The serial mediation effects were examined using Model 6 in the Hayes' PROCESS macro for SPSS.

RESULTS

The results showed that SMA among college students had a direct negative relationship with their academic engagement (Effect = - 0.051, 95% CI: -0.087 to - 0.015). In addition, sleep quality and fatigue mediated the relationship between SMA and academic engagement both independent and serially, with the independent mediation effect of sleep quality being - 0.031 (95% CI: -0.048 to - 0.016), the independent mediation effect of fatigue being - 0.109 (95% CI: -0.133 to - 0.088), and the serial mediation effect of sleep quality and fatigue being - 0.080 (95% CI: -0.095 to - 0.066). The total indirect effect of the three mediation paths was 80.9%.

CONCLUSIONS

Decreased academic engagement caused by SMA can be aggravated by poor sleep quality and fatigue. Strengthening supervision and intervention in social media use among college students, supplemented by attention to psychosomatic health, including sleep quality and fatigue could promote their engagement in academic work.

Development of an Integrated Human Error Simulation Model in Nuclear Power Plant Decommissioning Activities

In this study, an integrated human error simulation model in nuclear power plant (NPP) decommissioning activities (HEISM-DA) that can integrate and manage various factors affecting human errors is developed. In the HEISM-DA, an error probability input method suitable for the characteristics of each performance shaping factors (PSFs) was presented. Because each PSF has different importance on human error, the relative importance of decommissioning PSF Levels 1 and 2 and influential factors is considered. A multiplier was selected for each PSF and then used for human error evaluation. To calculate the human error probability (HEP) for the NPP decommissioning activity, the relationship between each PSF is identified and linked to develop a human error evaluation model. Using the HEISM-DA, HEP for reactor pressure vessel internal cutting work is evaluated based on the experience data. HEP is calculated to be approximately 1%. As a result of HEP calculation, it is found that the “operation” factor has a significant influence on the HEP of NPP decommissioning activities. Therefore, if the dismantling work is conducted by supervising the “operation” factors in a detailed and systematic approach, it is believed that the HEP will be reduced as other factors are also affected.

Health system support among patients with ME/CFS in Switzerland

Objectives

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex chronic and debilitating multifactorial disease. Adequate patient care is challenged by poor knowledge among health care professionals and the historical misconception that the disease is psychological in nature. This study assessed the health-related challenges faced by patients with ME/CFS in Switzerland and examined whether they receive adequate health care.

Methods

Quantitative and qualitative data were collected through a self-administered questionnaire between June and September of 2021, among 169 patients with ME/CFS in Switzerland.

Results

The mean age at diagnosis was 38.8 years. Only one-third of ME/CFS affected children and youth were correctly diagnosed before their 18th birthday. The mean time from disease onset to diagnosis was 6.7 years, and patients had an average of 11.1 different appointments and 2.6 misdiagnoses. A poor diagnosis rate and insufficient disease knowledge among health professionals in Switzerland led 13.5% of the patients to travel abroad to seek a diagnosis. Most patients (90.5%) were told at least once that their symptoms were psychosomatic. Swiss patients expressed high dissatisfaction with the health system and indicated that physicians lacked knowledge regarding ME/CFS. Therapies prescribed by physicians or tried by patients, as well as their perceived efficacy, were described. Graded Exercise Therapy (GET) was perceived as harmful by patients, whereas pacing, complementary/alternative medicine, and dietary supplements and medications to alleviate symptoms were reported to be helpful to varying degrees.

Conclusion

This study highlights that poor disease knowledge among health care providers in Switzerland has led to high patient dissatisfaction, and delays in ME/CFS diagnoses and prescription of inappropriate therapies, thus adding to patient distress and disease burden.

Systemic antibody responses against human microbiota flagellins are overrepresented in chronic fatigue syndrome patients

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a debilitating disease with an unclear etiology and pathogenesis. Both an involvement of the immune system and gut microbiota dysbiosis have been implicated in its pathophysiology. However, potential interactions between adaptive immune responses and the microbiota in ME/CFS have been incompletely characterized. Here, we profiled antibody responses of patients with severe ME/CFS and healthy controls against microbiota and viral antigens represented as a phage-displayed 244,000 variant library. Patients with severe ME/CFS exhibited distinct serum antibody epitope repertoires against flagellins of Lachnospiraceae bacteria. Training machine learning algorithms on this antibody-binding data demonstrated that immune responses against gut microbiota represent a unique layer of information beyond standard blood tests, providing improved molecular diagnostics for ME/CFS. Together, our results point toward an involvement of the microbiota-immune axis in ME/CFS and lay the foundation for comparative studies with inflammatory bowel diseases and illnesses characterized by long-term fatigue symptoms, including post-COVID-19 syndrome.

Treatments of chronic fatigue syndrome and its debilitating comorbidities: a 12-year population-based study

Background

This study aims to provide 12-year nationwide epidemiology data to investigate the epidemiology and comorbidities of and therapeutic options for chronic fatigue syndrome (CFS) by analyzing the National Health Insurance Research Database.

Methods

6306 patients identified as having CFS during the 2000–2012 period and 6306 controls (with similar distributions of age and sex) were analyzed.

Result

The patients with CFS were predominantly female and aged 35–64 years in Taiwan and presented a higher proportion of depression, anxiety disorder, insomnia, Crohn’s disease, ulcerative colitis, renal disease, type 2 diabetes, gout, dyslipidemia, rheumatoid arthritis, Sjogren syndrome, and herpes zoster. The use of selective serotonin receptor inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), Serotonin antagonist and reuptake inhibitors (SARIs), Tricyclic antidepressants (TCAs), benzodiazepine (BZD), Norepinephrine-dopamine reuptake inhibitors (NDRIs), muscle relaxants, analgesic drugs, psychotherapies, and exercise therapies was prescribed significantly more frequently in the CFS cohort than in the control group.

Conclusion

This large national study shared the mainstream therapies of CFS in Taiwan, we noticed these treatments reported effective to relieve symptoms in previous studies. Furthermore, our findings indicate that clinicians should have a heightened awareness of the comorbidities of CFS, especially in psychiatric problems.

Co-occurrence of Fatigue and Depression in People With Multiple Sclerosis: A Mini-Review

Fatigue and depression are common conditions diagnosed in people with multiple sclerosis (MS). Fatigue defined as subjective lack of physical and/or mental energy is present in 35–97% of people with MS, who classify it as one of the most serious symptoms interfering with daily activities and influencing the quality of life. Depression is diagnosed in about 50% of people with MS. Since fatigue and depression frequently coexists, it may be quite hard to differentiate them. Primary fatigue and primary depression in MS are caused by inflammatory, oxidative/nitrosative, and neurodegenerative processes leading to demyelination, axonal damage, and brain atrophy. In people with MS and comorbid fatigue and/or depression there is reported increased serum and cerebrospinal fluid concentration of inflammatory mediators such as tumor necrosis factor, interleukins (IL-1a, IL-1b, IL-6), interferon γ and neopterin. Moreover, the brain atrophy of prefrontal, frontal, parietotemporal regions, thalamus, and basal ganglia was observed in people with MS with fatigue and/or depression. The secondary fatigue and secondary depression in people with MS may be caused by emotional factors, sleep disorders, pain, the coexistence of other diseases, and the use of medications. In some studies, the use of disease-modifying therapies positively influenced fatigue, probably by reducing the inflammatory response, which proves that fatigue and depression are closely related to immunological factors. In this mini-review, the pathogenesis, methods of evaluation and differentiation, and possible therapies for fatigue and depression in MS are discussed.

Commonalities in the Features of Cancer and Chronic Fatigue Syndrome (CFS): Evidence for Stress-Induced Phenotype Instability?

Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) and Cancer-Related Fatigue (CRF) are syndromes with considerable overlap with respect to symptoms. There have been many studies that have compared the two conditions, and some of this research suggests that the etiologies of the conditions are linked in some cases. In this narrative review, CFS/ME and cancer are introduced, along with their known and putative mechanistic connections to multiple stressors including ionizing radiation. Next, we summarize findings from the literature that suggest the involvement of HPA-axis dysfunction, the serotonergic system, cytokines and inflammation, metabolic insufficiency and mitochondrial dysfunction, and genetic changes in CRF and CFS/ME. We further suspect that the manifestation of fatigue in both diseases and its causes could indicate that CRF and CFS/ME lie on a continuum of potential biological effects which occur in response to stress. The response to this stress likely varies depending on predisposing factors such as genetic background. Finally, future research ideas are suggested with a focus on determining if common biomarkers exist in CFS/ME patients and those afflicted with CRF. Both CFS/ME and CRF are relatively heterogenous syndromes, however, it is our hope that this review assists in future research attempting to elucidate the commonalities between CRF and CFS/ME.

The maintained attention assessment in patients affected by Myalgic encephalomyelitis/chronic fatigue syndrome: a reliable biomarker?

The maintained attention is the cause of great functional limitations in CFS/ME, a disease that mainly affects women in the central period of life. Cognitive function is explored using the Montreal Cognitive Assessment, the maintained attention using the Toulouse-Piéron test with which the Global Index of Attention and Perception (GIAP) is obtained, the fatigue using the visual analog scale and the perception of effort using the modified Borg scale. The final sample were 84 patients (66 women/18 men) who met diagnostic criteria (Fukuda-1994, Carruthers-2011) and 22 healthy controls (14 women/8 men). Most of patients maintain normal cognitive function, showing low or very low attention score in the 70% of patients with a marked cognitive fatigue compared to the control group (p < 0.05). There were no significant differences between genders in GIAP or fatigue for CFS/ME; however, sick women perceive cognitive effort higher than men. Deficits in sustained attention and the perception of fatigue, so effort after performing the proposed test are a sensitive and reliable indicator that allows us to substantiate a clinical suspicion and refer patients for further studies in order to confirm or rule out CFS/ME.

Korean Red Ginseng Ameliorates Fatigue via Modulation of 5-HT and Corticosterone in a Sleep-Deprived Mouse Model

Central fatigue, which is neuromuscular dysfunction associated with neurochemical alterations, is an important clinical issue related to pathologic fatigue. This study aimed to investigate the anti-central fatigue effect of Korean red ginseng (KRG) and its underlying mechanism. Male BALB/c mice (8 weeks old) were subjected to periodic sleep deprivation (SD) for 6 cycles (forced wakefulness for 2 days + 1 normal day per cycle). Simultaneously, the mice were administered KRG (0, 100, 200, or 400 mg/kg) or ascorbic acid (100 mg/kg). After all cycles, the rotarod and grip strength tests were performed, and then the changes regarding stress- and neurotransmitter-related parameters in serum and brain tissue were evaluated. Six cycles of SD notably deteriorated exercise performance in both the rotarod and grip strength tests, while KRG administration significantly ameliorated these alterations. KRG also significantly attenuated the SD-induced depletion of serum corticosterone. The levels of main neurotransmitters related to the sleep/wake cycle were markedly altered (serotonin was overproduced while dopamine levels were decreased) by SD, and KRG significantly attenuated these alterations through relevant molecules including brain-derived neurotropic factor and serotonin transporter. This study demonstrated the anti-fatigue effects of KRG in an SD mouse model, indicating the clinical relevance of KRG.

Radiation exposure and mitochondrial insufficiency in chronic fatigue and immune dysfunction syndrome

Chronic fatigue and Immune Dysfunction Syndrome (CFIDS) is a heterogeneous disease that may be promoted by various environmental stressors, including viral infection, toxin uptake, and ionizing radiation exposure. Previous studies have identified mitochondrial dysfunction in CFIDS patients, including modulation of mitochondrial respiratory chain activity, deletions in the mitochondrial genome, and upregulation of reactive oxygen species (ROS). This paper focuses on radiation effects and hypothesizes that CFIDS is primarily caused by stressor-induced mitochondrial metabolic insufficiency, which results in decreased energy production and anabolic metabolites required for normal cellular metabolism. Furthermore, tissues neighbouring or distant from directly perturbed tissues compensate for this dysfunction, which causes symptoms associated with CFIDS. This hypothesis is justified by reviewing the links between radiation exposure and CFIDS, cancer, immune dysfunction, and induction of oxidative stress. Moreover, the relevance of mitochondria in cellular responses to radiation and metabolism are discussed and putative mitochondrial biomarkers for CFIDS are introduced. Implications for diagnosis are then described, including a potential urine assay and PCR test for mitochondrial genome mutations. Finally, future research needs are offered with an emphasis on where rapid progress may be made to assist the afflicted.

Increasing the Clinical Utility of the Paced Auditory Serial Addition Test: Normative Data for Standard, Dyad, and Cognitive Fatigability Scoring

BACKGROUND

No normative data currently exist that would allow clinicians to decide whether the degree of cognitive fatigability (CF) experienced in individuals with neurologic disease is greater than expected when compared with a healthy population.

OBJECTIVE

To establish discrete and regression-based normative data for CF as defined by an objective decrement in performance over the course of a cognitive task; namely, the Paced Auditory Serial Addition Test (PASAT). In addition, to develop discrete and regression-based normative data for PASAT performance scores-dyad and percent dyad-for which data do not currently exist.

METHOD

One hundred and seventy-eight healthy individuals completed the PASAT as part of a larger neuropsychological battery. PASAT performance scores including total correct responses, total dyads, and percent dyad were calculated. CF scores were calculated by comparing the individuals' performance on the first half (or third) of the test to their performance on the last half (or third) in order to capture any within-task performance decrements over time.

RESULTS

Both age- and education-based discrete normative data and demographically adjusted (sex, age, and education) regression-based formulas were established for the PASAT performance scores and the CF scores.

CONCLUSION

The development of these normative data will allow for greater interpretation of an individual's performance on the PASAT, beyond just the total correct score, through the use of dyad and percent dyad scores. With respect to CF, these data will allow clinicians to objectively quantify decrements in cognitive performance over time better in individuals with neurologic diseases.

Potential role of microbiome in Chronic Fatigue Syndrome/Myalgic Encephalomyelits (CFS/ME)

Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) is a severe multisystemic disease characterized by immunological abnormalities and dysfunction of energy metabolism. Recent evidences suggest strong correlations between dysbiosis and pathological condition. The present research explored the composition of the intestinal and oral microbiota in CFS/ME patients as compared to healthy controls. The fecal metabolomic profile of a subgroup of CFS/ME patients was also compared with the one of healthy controls. The fecal and salivary bacterial composition in CFS/ME patients was investigated by Illumina sequencing of 16S rRNA gene amplicons. The metabolomic analysis was performed by an UHPLC-MS. The fecal microbiota of CFS/ME patients showed a reduction of Lachnospiraceae, particularly Anaerostipes, and an increased abundance of genera Bacteroides and Phascolarctobacterium compared to the non-CFS/ME groups. The oral microbiota of CFS/ME patients showed an increase of Rothia dentocariosa. The fecal metabolomic profile of CFS/ME patients revealed high levels of glutamic acid and argininosuccinic acid, together with a decrease of alpha-tocopherol. Our results reveal microbial signatures of dysbiosis in the intestinal microbiota of CFS/ME patients. Further studies are needed to better understand if the microbial composition changes are cause or consequence of the onset of CFS/ME and if they are related to any of the several secondary symptoms.

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS): Where will the drugs come from?

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic debilitating disease characterized by severe and disabling fatigue that fails to improve with rest; it is commonly accompanied by multifocal pain, as well as sleep disruption, and cognitive dysfunction. Even mild exertion can exacerbate symptoms. The prevalence of ME/CFS in the U.S. is estimated to be 0.5-1.5 % and is higher among females. Viral infection is an established trigger for the onset of ME/CFS symptoms, raising the possibility of an increase in ME/CFS prevalence resulting from the ongoing COVID-19 pandemic. Current treatments are largely palliative and limited to alleviating symptoms and addressing the psychological sequelae associated with long-term disability. While ME/CFS is characterized by broad heterogeneity, common features include immune dysregulation and mitochondrial dysfunction. However, the underlying mechanistic basis of the disease remains poorly understood. Herein, we review the current understanding, diagnosis and treatment of ME/CFS and summarize past clinical studies aimed at identifying effective therapies. We describe the current status of mechanistic studies, including the identification of multiple targets for potential pharmacological intervention, and ongoing efforts towards the discovery of new medicines for ME/CFS treatment.

Relationship of Problematic Smartphone Use, Sleep Quality, and Daytime Fatigue Among Quarantined Medical Students During the COVID-19 Pandemic

Background: The COVID-19 pandemic brought about great transformation to medical education mode. Although mobile communication devices played a crucial role in online learning among quarantined university students, the potential smartphone addition problems, negative health behaviors, and psychological symptoms need considerable attention. This study examined the relationship of problematic smartphone use (PSU), sleep quality, and daytime fatigue among medical students. Methods: A web-based survey was conducted in six polyclinic hospitals in Beijing between February and May 2020. 1016 participants (26.01 ± 2.46 years, 65.16% female) completed self-report measurements including Short Version Smartphone Addiction Scale (SAS-SV), Athens Insomnia Scale (AIS), and Subjective Fatigue Scale (FS). Spearman correlation coefficients and multiple regression models were used to analyze the association among PSU, sleep quality, and daytime fatigue. We used structural equation modeling to test the mediating effect of sleep quality between PSU and daytime fatigue. Results: 49.70% of the participants had PSU. Significant positive correlations were found among SAS-SV, AIS, and FS scores (r = 0.35-0.61, P _S < 0.001). Subjects with PSU were more likely to report sleep disturbance (β = 1.07, P < 0.001, OR = 2.91, 95%CI = 2.17-3.91), physical fatigue (β = 1.16, P < 0.001, OR = 3.18, 95%CI = 2.45-4.15), and mental fatigue (β = 0.88, P < 0.001, OR = 2.42, 95%CI = 1.86-3.14). The indirect effect of PSU on physical fatigue and mental fatigue mediated by sleep quality accounted for 50.03 and 45.43% of the total effect, respectively. Conclusions: PSU was significantly associated with sleep disturbance and fatigue among medical students during the COVID-19 pandemic. Sleep quality mediated the relationship between PSU and daytime fatigue. Our results provide valuable information for maintaining medical students' health status and constructing online education structures.

Changes in the levels of IL-1β, cortisol and chromogranin A in saliva of subjects with occupational fatigue

Changes in the levels of interleukin-1β (IL-1β), cortisol and chromogranin A (CgA) in saliva of subjects with occupational fatigue were investigated. Doctors in the Emergency Department were selected as research subjects. Saliva was collected before work (after full rest) and after work (≥24 h). Electroencephalogram (EEG) was performed. Enzyme-linked immunosorbent assay (ELISA) was used to detect the levels of IL-1β, cortisol and CgA in saliva. In order to obtain permission for human specimens, the study was approved by the Ethics Committee of the Affiliated Hospital of Hebei University of Engineering and registered for clinical trials (registration no. ChiC-TR-DCD-14005746). As there were only 4 subjects in this study without fatigue waves in EEG, and the number of these subjects was not sufficient to constitute a control group, the comparison of the contents of IL-1β, cortisol and CgA of all subjects before and after working for 18 h was just a confirmation of the statistical results of 43 cases with fatigue waves in the EEG. According to the results, there was no change in the contents of IL-1β and cortisol in the saliva of subjects with occupational fatigue before and after fatigue, whereas, there was a significant change in the content of CgA before and after fatigue. However, there was no correlation between the content of CgA and fatigue. The results of the present study revealed that IL-1β, cortisol and CgA indicators are not suitable diagnostic markers for occupational fatigue.

Possible adrenal insufficiency among fatigue patients in a psychosomatic medical clinic

Fatigue is a common symptom in patients visiting the clinic of psychosomatic medicine. A 250-μg synthetic ACTH (1-24) test (rapid ACTH test) and Beck depression inventory (BDI) were performed for 62 patients presenting with fatigue who visited the Department of Psychosomatic Medicine at Fukuoka Tokushukai Hospital. Patients were divided into 3 groups according to the serum cortisol response to the rapid ACTH test; those with a peak serum cortisol level of <15 μg/dL were defined as the adrenal insufficiency (AI) probable group, ≥15 μg/dL and <18 μg/dL as the AI suspected group, and ≥18 μg/dL as the non-AI group. Patients prescribed anti-depressants, had a BDI ≥16, and/or met the full criteria for major depression were diagnosed with depression. Five (8.0%) and 7 patients (11.3%) were assigned to the AI probable and AI suspected groups, respectively. All others were assigned to the non-AI group. Depression was observed in 37 patients (59.6%; 4 in the AI probable group [80.0%], 4 in the AI suspected group [57.1%], and 29 in the non-AI group [58.0%]). Users of exogenous steroids, such as inhaled steroids for bronchial asthma, were seen in the AI probable group (2; 40.0%), the AI suspected group (3; 42.8%), and the non-AI group (7; 14.0%) (χ² = 4.761, p = 0.0925). In conclusion, probable or suspected AI was observed in about one-fifth of patients presenting with fatigue at the psychosomatic medical clinic. A CRH test and insulin tolerance test (ITT) may help the he mechanism underlying these possible AIs.

An Adrenalectomy Mouse Model Reflecting Clinical Features for Chronic Fatigue Syndrome

Chronic fatigue syndrome (CFS) is one of the most intractable diseases and is characterized by severe central fatigue that impairs even daily activity. To date, the pathophysiological mechanisms are uncertain and no therapies exist. Therefore, a proper animal model reflecting the clinical features of CFS is urgently required. We compared two CFS animal models most commonly used, by injection with lipopolysaccharide (LPS from Escherichia coli O111:B4) or polyinosinic: polycytidylic acid (poly I:C), along with bilateral adrenalectomy (ADX) as another possible model. Both LPS- and poly I:C-injected mice dominantly showed depressive behaviors, while ADX led to fatigue-like performances with high pain sensitivity. In brain tissues, LPS injection notably activated microglia and the 5-hydroxytryptamine (HT)1A receptor in the prefrontal cortex and hippocampus. Poly I:C-injection also remarkably activated the 5-HT transporter and 5-HT1A receptor with a reduction in serotonin levels in the brain. ADX particularly activated astrocytes and transforming growth factor beta (TGF-β) 1 in all brain regions. Our results revealed that LPS and poly I:C animal models approximate depressive disorder more closely than CFS. We suggest that ADX is a possible method for establishing a mouse model of CFS reflecting clinical features, especially in neuroendocrine system.

miR-200a-3p modulates gene expression in comorbid pain and depression: Molecular implication for central sensitization

Chronic pain and depression are often comorbid exhibiting common clinical presentations and biological connections related to central nervous system sensitization. Epigenetic regulation of gene expression in the brain plays a crucial role in response to long-lasting stress and chronic pain, and microRNA imbalance in the prefrontal cortex (PFC) might be involved in central sensitization. Male Sprague Dawley rats were subjected to unpredictable chronic mild stress (UCMS) and spared nerve injury (SNI) to initiate depressive-like behavior and chronic pain behavior, respectively. The next-generation sequencing technique was employed to analyze PFC microRNAs in both the UCMS and SNI models. Rats exposed to either UCMS or SNI exhibited both depressive-like and chronic pain behaviors. Five specific microRNAs (miR-10a-5p, miR-182, miR-200a-3p, miR-200b-3p, and miR-429) were simultaneously down-regulated in the depressive-like and chronic pain models after 4 weeks of short-term stress. Gene ontology revealed that the 4-week period of stress enhanced neurogenesis. Only the miR-200a-3p level was continuously elevated under prolonged stress, suggesting roles of reduced neurogenesis, inflammatory activation, disturbed circadian rhythm, lipid metabolism, and insulin secretion in the co-existence of pain and depression. Thus we conclude that miR-200a-3p might be a specific biomarker of central sensitization in chronic pain and depression.

Evidence for similarity in symptoms and mechanism: The extra-pulmonary symptoms of severe asthma and the polysymptomatic presentation of fibromyalgia

BACKGROUND

Asthma is a disease of the lung and a systemic disease. Functional disorders are associated with multiple systemic abnormalities that have been explained by complexity models. The aim was to test the similarity in type and aetiology between the extra-pulmonary symptoms of severe asthma and the symptoms of fibromyalgia.

METHODS

One Hundred patients recruited from a specialist severe asthma clinic and 1751 people reporting different functional disorder diagnoses recruited via the internet completed the same 60-item questionnaire. Symptom patterns were compared between groups using a new measure, the symptom pattern similarity index where 0 = no relationship, 1 = identical patterns between groups.

RESULTS

Severe asthma patients report numerous extra-pulmonary symptoms. The similarity index between the symptom pattern of the asthma patients with other groups was irritable bowel syndrome = 0.54, chronic fatigue syndrome = 0.69, and fibromyalgia = 0.75. The index between fibromyalgia and asthma patients with the most and least frequent extra-pulmonary symptoms was 0.81 and 0.55 respectively.

CONCLUSIONS

Patients with severe asthma have numerous extra-pulmonary symptoms similar in type and pattern to the symptoms of fibromyalgia. The similarity of the symptom pattern between asthma and fibromyalgia increases as the number of extra-pulmonary symptoms increases as predicted by network theory and previously shown to be the case with other functional disorders. These findings support the hypothesis that functional disorders and extra-pulmonary asthma symptoms have a common complexity or network aetiology. Evidence based behavioural interventions for fibromyalgia may be helpful for patients with severe asthma reporting extra-pulmonary symptoms.

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Comprehensive Review

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.

Changes in tinnitus and physiological biomarkers of stress in response to short-term broadband noise and sounds of nature

BACKGROUND

Tinnitus is the perception of sound when no external sound source is present. In some cases, this perception coincides with, or results in, stress. Tinnitus-related distress has been associated with increased levels of cortisol and elevated levels of sympathetic tone. Our primary hypothesis was that short-term sound exposure would reduce tinnitus perception and various physiological measures of stress. A secondary hypothesis was that a self-selected nature sound would reduce physiological markers of stress more than broadband noise.

METHODS

Twenty-one participants with constant bothersome tinnitus underwent an audiological assessment. Measurements of blood pressure, heart rate, salivary cortisol and cortisone concentrations, and tinnitus ratings were carried out three times: prior to and, in a counterbalance order, after 30 min of broadband noise and after 30 min of a self-selected nature sound (from: ocean waves, stream, rain or shower sounds).

RESULTS

Findings revealed significant reductions in blood pressure measurements following broadband noise. None of the other stress measures demonstrated a statistically significant change. Both broadband noise and nature sounds elicited significant improvements in ratings of tinnitus.

CONCLUSIONS

While both sound types had a positive impact on many dimensions of tinnitus, only the broadband noise was associated with a reduction in blood pressure. These results are consistent with a complex interaction between sound and tinnitus and suggest a multifactorial basis to sound therapy that includes a reduction in arousal.

Increased risk of chronic fatigue syndrome following psoriasis: a nationwide population-based cohort study

BACKGROUND

The onset of chronic fatigue syndrome (CFS) has been shown to be associated with several immunological conditions such as infections or atopy. The aim of this study was to clarify the risk of chronic fatigue syndrome following the diagnosis of psoriasis, an immune-related dermatological disease, by analyzing the National Health Insurance Research Database of Taiwan.

METHOD

2616 patients aged 20 years or older with newly diagnosed psoriasis during 2004-2008 and 10,464 participants without psoriasis were identified. Both groups were followed up until the diagnoses of CFS were made at the end of 2011.

RESULTS

The relationship between psoriasis and the subsequent risk of CFS was estimated through Cox proportional hazards regression analysis, with the incidence density rates being 2.27 and 3.58 per 1000 person-years among the non-psoriasis and psoriasis populations, respectively (adjusted hazard ratio [HR] = 1.48, with 95% confidence interval [CI] 1.07-2.06). In the stratified analysis, the psoriasis group were consistently associated with a higher risk of CFS in male sex (HR = 2.05, 95% CI 1.31-3.20) and age group of ≥ 60 years old (HR = 2.32, 95% CI 1.33-4.06). In addition, we discovered that the significantly increased risk of CFS among psoriasis patients is attenuated after they receive phototherapy and/or immunomodulatory drugs.

CONCLUSIONS

The data from this population-based retrospective cohort study revealed that psoriasis is associated with an elevated risk of subsequent CFS, which is differentiated by sex and age.

The role of neuro-immune interactions in cancer-related fatigue: Biobehavioral risk factors and mechanisms

Fatigue is a common and distressing symptom in both patients with cancer and cancer survivors. There is substantial variation in the severity and persistence of cancer-related fatigue that may be driven by individual differences in host factors, including characteristics that predate the cancer experience as well as responses to cancer and its treatment. This review examines biobehavioral risk factors linked to fatigue and the mechanisms through which they influence fatigue across the cancer continuum, with a focus on neuro-immune processes. Among psychosocial risk factors, childhood adversity is a strong and consistent predictor of cancer-related fatigue; other risk factors include history of depression, catastrophizing, lack of physical activity, and sleep disturbance, with compelling preliminary evidence for loneliness and trait anxiety. Among biologic systems, initial work suggests that alterations in immune, neuroendocrine, and neural processes are associated with fatigue. The identification of key risk factors and underlying mechanisms is critical for the development and deployment of targeted interventions to reduce the burden of fatigue in the growing population of cancer survivors. Given the multidimensional nature of fatigue, interventions that influence multiple systems may be most effective.

Effect of Coelogyne cristata Lindley in alleviation of chronic fatigue syndrome in aged Wistar rats

BACKGROUND

Swarna Jibanti scientifically known as Coelogyne cristata Lindley (Orchidaceae), an orchid mentioned in Ayurvedic medicine is used to promote healthy life span.

OBJECTIVE(S)

The present work was planned to study the efficacy of hydro-alcoholic extract of pseudobulbs of C. cristata (CCE) to assess its role on chronic fatigue syndrome (CFS) induced behavioural and biochemical changes in aged Wistar rats compared to Panax ginseng (PG), a prototype anti-stress agent.

MATERIALS AND METHODS

CFS was induced by forced swimming for consecutive 21 days for fixed duration (15 min sessions). The criteria of CFS due to fatigue were counted using locomotor activity, depression and anxiety through automated photactometer, immobility time and plus maze activity respectively. Acute toxicity study of CCE (upto 2 g/kg, Limit test) was also performed. For CFS, animals were divided into five groups, naive control, control, CCE treated (25 mg/kg b.w., 250 mg/kg b.w.) and standard PG treated (100 mg/kg b.w.) groups. All drugs were given orally for consecutive 21 days along with CFS. After assessing behavioural parameters, all animals were sacrificed at day 21 and in vivo antioxidant potential of CCE was determined by lipid peroxides, nitrite, catalase (CAT) and superoxide dismutase (SOD) in brain tissue.

RESULTS

CCE was found to be non-toxic. CCE treated aged rats significantly improved (p < 0.001) the spontaneous locomotor movement with respect to control rats, while, decreased the mobility period or depression score. In CFS, CCE also enhanced the time spent (p < 0.001) in open arms while reducing the time spent in closed arm as compared to CFS control, indicating lowering anxiety score. Moreover, marked diminution in lipid peroxidation, nitrite and SOD level was exhibited after CCE treatment and significantly enhanced catalase level significantly (p < 0.01) with respect to CFS control. PG also showed similar actions.

CONCLUSION

The results confirmed the potential therapeutic actions of CCE against experimentally induced CFS in aged rats that might be due to its CNS mediatory antioxidant properties.

Reduction of Glucocorticoid Receptor Function in Chronic Fatigue Syndrome

Glucocorticoid receptor (GR) function may have aetiopathogenic significance in chronic fatigue syndrome (CFS), via its essential role in mediating inflammatory responses as well as in hypothalamic-pituitary-adrenal axis regulation. GR function can be estimated ex vivo by measuring dexamethasone (dex) modulation of cytokine response to lipopolysaccharide (LPS), and in vivo using the impact of dex on cortisol levels. This study aimed to compare the GR function between CFS (n = 48), primary Sjögren's syndrome (a disease group control) (n = 27), and sedentary healthy controls (HCs) (n = 20), and to investigate its relationship with clinical measures. In the GR ex vivo response assay, whole blood was diluted and incubated with LPS (to stimulate cytokine production), with or without 10 or 100 nanomolar concentrations of dex. Cytometric bead array (CBA) and flow cytometry enabled quantification of cytokine levels (TNFα, interleukin- (IL-) 6, and IL-10) in the supernatants. In the in vivo response assay, five plasma samples were taken for determination of total cortisol concentration using ELISA at half-hourly intervals on two consecutive mornings separated by ingestion of 0.5 mg of dex at 11 pm. The association of the data from the in vivo and ex vivo analyses with reported childhood adversity was also examined. CFS patients had reduced LPS-induced IL-6 and TNFα production compared to both control groups and reduced suppression of TNFα by the higher dose of dex compared to HCs. Cortisol levels, before or after dex, did not differ between CFS and HCs. Cortisol levels were more variable in CFS than HCs. In the combined group (CFS plus HC), cortisol concentrations positively and ex vivo GR function (determined by dex-mediated suppression of IL-10) negatively correlated with childhood adversity score. The results do not support the hypothesis that GR dysregulation is aetiopathogenic in CFS and suggest that current and future endocrine cross-sectional studies in CFS may be vulnerable to the confounding influence of childhood trauma which is likely increased by comorbid depression.

Multimodal Regulation of Circadian Glucocorticoid Rhythm by Central and Adrenal Clocks

Adrenal glucocorticoids (GCs) control a wide range of physiological processes, including metabolism, cardiovascular and pulmonary activities, immune and inflammatory responses, and various brain functions. During stress responses, GCs are secreted through activation of the hypothalamic-pituitary-adrenal axis, whereas circulating GC levels in unstressed states follow a robust circadian oscillation with a peak around the onset of the active period of a day. A recent advance in chronobiological research has revealed that multiple regulatory mechanisms, along with classical neuroendocrine regulation, underlie this GC circadian rhythm. The hierarchically organized circadian system, with a central pacemaker in the suprachiasmatic nucleus of the hypothalamus and local oscillators in peripheral tissues, including the adrenal gland, mediates periodicities in physiological processes in mammals. In this review, we primarily focus on our understanding of the circadian regulation of adrenal GC rhythm, with particular attention to the cooperative actions of the suprachiasmatic nucleus central and adrenal local clocks, and the clinical implications of this rhythm in human diseases.

Short-term and long-term measures of cortisol in saliva and hair in atypical and non-atypical depression

BACKGROUND

Atypical depression may show lowered rather than raised short-term cortisol levels. Atypical major depressive episodes (A-MDE) may also be more closely linked to environmental factors and show overlap with somatic symptom disorders. Hair specimens allow measuring long-term cortisol levels.

METHODS

Twenty-seven A-MDE and 44 NA-MDE patients and 40 matched controls were tested. Measures of hair cortisol concentration [HCC] covering the previous 3 months and short-term cortisol parameters (six saliva specimens to assess the cortisol awakening response [CAR] and total daily cortisol output calculated as the area under the curve [AUCg]) were taken alongside measures of environmental factors and clinical variables.

RESULTS

There were no differences in HCC between the three groups (P = 0.8), and no difference in the CAR (P = 0.95). However, A-MDE showed lowered short-term cortisol output (AUCg) compared to controls (P = 0.04). A-MDE patients also reported a higher number of daily hassles, and higher levels of fatigue and impaired concentration than NA-MDE.

CONCLUSIONS

Normal long-term (HCC) and reduced short-term (AUCg) cortisol levels in A-MDE could suggest a disrupted long-term cortisol rhythm, perhaps affected by environmental factors or by certain symptoms, such as mid-nocturnal insomnia. However, other underlying explanations for these findings should also be investigated in the future.

Elevated fingernail cortisol levels in major depressive episodes

BACKGROUND

The extent to which cortisol levels are elevated in major depressive episodes (MDE), and hence could act as a biomarker of illness, remains unclear. Although patient characteristics may explain some of this variation - for example elevated cortisol being more often found in patients with severe, psychotic or melancholic depression - problems with the methods used to measure cortisol may also have contributed to the inconsistent findings. Fingernails are a novel sample that can be used to assess aggregate cortisol concentrations over a 15-day period, and may provide a more accurate reflection of longer term cortisol level changes in MDE and help clarify this issue. This methodology has not yet been utilised in MDE.

METHODS

Cortisol levels reflecting a period of 15days were measured using fingernails in a group of 26 subjects experiencing a major depressive episode (MDE) and in an age and gender matched group of 45 healthy controls.

RESULTS

Depressed subjects showed significantly higher mean cortisol levels measured in fingernails when compared with control subjects. Higher levels of cortisol were associated with higher depression severity scores, a diagnosis of non-reactive depression, and more prominent melancholic symptoms. Conversely, fatigue was negatively correlated with cortisol levels.

CONCLUSION

There is elevated cortisol in MDE when assessed using an aggregate measure over two weeks.Alterations in fingernail cortisol correlate with key clinical symptoms and subtypes of depression.

A test of the adaptive network explanation of functional disorders using a machine learning analysis of symptoms

The classification and etiology of functional disorders is controversial. Evidence supports both psychological and biological (disease) models that show, respectively, that functional disorders should be classified as one (bodily distress syndrome) and many (e.g., irritable bowel syndrome (IBS), fibromyalgia syndrome (FMS), and chronic fatigue syndrome (CFS)). Two network models (symptom network and adaptive network) can explain the specificity and covariation of symptomatology, but only the adaptive network model can explain the covariation of the somatic symptoms of functional disorders. The adaptive network model is based on the premise that a network of biological mechanisms has emergent properties and can exhibit adaptation. The purpose of this study was to test the predictions that symptom similarity increases with pathology and that network connection strengths vary with pathology, as this would be consistent with the notion that functional disorder pathology arises from network adaptation. We conducted a symptom internet survey followed by machine learning analysis. Participants were 1751 people reporting IBS, FMS or CFS diagnosis who completed a 61-item symptom questionnaire. Eleven symptom clusters were identified. Differences in symptom clusters between IBS, FMS and CFS groups decreased as overall symptom frequency increased. The strength of outgoing connections between clusters varied as a function of symptom frequency and single versus multiple diagnoses. The findings suggest that the pathology of functional disorders involves an increase in the activity and causal connections between several symptom causing mechanisms. The data provide support for the proposal that the body is capable of complex adaptation and that functional disorders result when rules that normally improve adaptation create maladaptive change.

Cancer-Related Fatigue in Cancer Survivorship

Cancer-related fatigue (CRF) significantly interferes with usual functioning because of the distressing sense of physical, emotional, and cognitive exhaustion. Assessment of CRF is important and should be performed during the initial cancer diagnosis, throughout cancer treatment, and after treatment using a fatigue scoring scale (mild-severe). The general approach to CRF management applies to cancer survivors at all fatigue levels and includes education, counseling, and other strategies. Nonpharmacologic interventions include psychosocial interventions, exercise, yoga, physically based therapy, dietary management, and sleep therapy. Pharmacologic interventions include psychostimulants. Antidepressants may also benefit when CRF is accompanied by depression.

Study of adrenal function in patients with tuberculosis

BACKGROUND

Although subclinical adrenal insufficiency has been documented in tuberculosis but it has been neglected in mainstream management of TB due to inconclusive data on its prevalence in TB. The fact that adrenal insufficiency may result not only in poor general condition of the patient but also sudden death due to adrenal crisis, makes it all the more important to address this issue seriously. In this non-randomized interventional study comprising of 100 cases of TB, our aim was to assess the adreno-cortical functions in patients with pulmonary TB (50 cases) and extra-pulmonary TB (50 cases) in an attempt to determine if there is any compromise of adrenal function.

METHODS

In this study, 100 cases of active TB were investigated for adrenal insufficiency by measuring morning fasting basal serum cortisol levels, followed by low dose ACTH stimulation test using 1μg synacthen (synthetic ACTH analog). The post-stimulation serum cortisol levels were estimated. Basal serum cortisol levels<220nmol/L or post-stimulation test serum cortisol level increment<200nmol/L or post-stimulation serum cortisol levels<500nmol/L were suggestive of adrenal insufficiency.

RESULTS

Basal serum cortisol level was low in 16% cases and after low dose ACTH stimulation test, cortisol response was subnormal in 76% cases. Incidence of adrenal insufficiency in pulmonary TB (74%) and extra-pulmonary TB (78%) were comparable. The number of females having adrenal insufficiency in both the groups was higher than the males (67.3% males and 83.3% females) but the difference was statistically significant only in extra-pulmonary TB group (p=0.011). On analysing the data, the sensitivity of basal serum cortisol level estimation in diagnosing adrenal insufficiency was observed to be 21.05% and its specificity was 100%. Positive predictive value was 100% and negative predictive value was 28.57%. Diagnostic accuracy of basal serum cortisol level estimation was observed to be 40%.

CONCLUSION

The incidence of subclinical adrenal insufficiency in TB cases attending chest department at a tertiary care hospital was significantly high but comparable in both pulmonary and extra-pulmonary type of TB. Females in general and particularly those with extra-pulmonary TB were observed to be at increased risk of adrenal insufficiency. The low dose ACTH stimulation test was able to identify cases with adrenal insufficiency which had normal basal serum cortisol levels. Screening all TB cases for adrenal insufficiency by measuring both morning basal serum cortisol levels and low dose ACTH stimulation test can help identify cases at risk of fatal adrenal crisis and institute timely management, thus improving disease prognosis.

Neuroendocrine disorder in chronic fatigue syndrome

Background/aim: Neuroendocrine disorders are considered a possible pathogenetic mechanism in chronic fatigue syndrome (CFS). The aim of our study was to determine the function of the hypothalamic-pituitary-adrenal axis (HPA) and thyroid function in women of reproductive age suffering from CFS. Materials and methods: The study included 40 women suffering from CFS and 40 healthy women (15-45 years old). Serum levels of cortisol (0800 and 1800 hours), ACTH, total T4, total T3, and TSH were measured in all subjects. The Fibro Fatigue Scale was used for determination of fatigue level. Results: Cortisol serum levels were normal in both groups. The distinctively positive moderate correlation of morning and afternoon cortisol levels that was observed in healthy women was absent in the CFS group. This may indicate a disturbed physiological rhythm of cortisol secretion. Although basal serum T4, T3, and TSH levels were normal in all subjects, concentrations of T3 were significantly lower in the CFS group. Conclusion: One-time hormone measurement is not sufficient to detect hormonal imbalance in women suffering from CFS. Absence of a correlation between afternoon and morning cortisol level could be a more representative factor for detecting HPA axis disturbance.

The cross-sectional relation between medically unexplained physical symptoms (MUPS) and the Cortisol Awakening Response

OBJECTIVES

We aimed to assess the cross-sectional relation between levels of cortisol and specific symptom clusters, symptom severity and duration of symptoms in patients with medically unexplained physical symptoms (MUPS).

METHODS

Baseline data of a cohort of MUPS patients were used. We chose the Cortisol Awakening Response (CAR) as a cortisol parameter, using saliva samples. We used confirmatory factor analysis for the identification of 4 specific symptom clusters: (1) gastro-intestinal symptoms; (2) pain; (3) cardio-pulmonary symptoms; and (4) fatigue. For this factor analysis we used the Physical Symptom Questionnaire (PSQ), which assesses the occurrence and frequency of 51 physical symptoms. Symptom severity was measured with the Patient Health Questionnaire-15 (PHQ-15). Duration of symptoms was based on self-reported duration of top 3 symptoms. We performed multiple linear regression to assess relations between CAR and individual factor scores on symptom clusters, symptom severity and duration of symptoms.

RESULTS

Data from 296 patients (76% female) were included in the analyses. The majority of patients suffered from symptoms in multiple organ systems. Factor analysis confirmed that the model with 4 symptom clusters fitted our data. For the total study population, we found no significant relation between CAR and participants' factor scores on any of the symptom clusters. We also found no significant relations between CAR and severity or duration of symptoms.

CONCLUSION

Our results suggest that within a heterogeneous MUPS population there is no relation between CAR and symptom severity and duration. However, more studies are needed to confirm our findings.

The Impact of Complicated Grief on Diurnal Cortisol Levels Two Years After Loss: A Population-Based Study

OBJECTIVE

Few studies have focused on the effect of complicated grief-unresolved and prolonged grief-on the neuroendocrine systems. The present study examined the association of complicated grief and normal grief with the diurnal cortisol patterns in a large population-based study.

METHODS

This study was set in the Rotterdam Study and comprised 2084 persons aged older than 55 years (mean [SD] age, 64.9 [5.5] years). Participants were assessed with the Complicated Grief Inventory and classified into no grief (n = 1922), normal grief (n = 131), or complicated grief (n = 31) if they experienced the loss in the past 2 years. Saliva samples were collected to measure cortisol levels. Morning cortisol and summary measures (area under the curve and the slope) were studied to account for the diurnal pattern of cortisol. Persons with depressive disorders were excluded, and analyses were additionally adjusted for depressive symptoms.

RESULTS

Compared to normal grievers, participants with complicated grief showed lower levels of morning cortisol (11.26 vs 15.51 nmol/L; difference, -4.24; 95% confidence interval [CI] = -7.87 to -0.62; p = .022), and lower levels of overall diurnal cortisol (6.89 vs 8.98 nmol/L; difference, -2.09; 95% CI = -3.81 to -0.37; p = .017). No difference was observed in slope between both groups. Participants with complicated grief also showed lower levels of morning cortisol than the nongrievers (11.26 vs 14.71; difference, -3.46; 95% CI = -6.78 to -0.13; p = .042). In contrast, cortisol secretion patterns did not differ between persons with normal grief and nongrieving controls.

CONCLUSIONS

Participants with complicated grief showed low levels of morning cortisol and low overall diurnal cortisol levels characteristic for a chronic stress reaction.

Plasma leptin concentration is associated with fatigue severity in patients with cardiovascular risk factors - HSCAA study

Fatigue induced by complex dysfunctions of the central nervous system is frequently complained by patients with cardiovascular risk factors. Although leptin is considered to regulate the central nervous system, there are no reports regarding its association with fatigue in those patients. This cross-sectional study included 347 patients with cardiovascular risk factors. Fatigue score and plasma leptin concentration were measured. In addition, abdominal fat accumulation, systemic inflammation, sleep condition, and functions of hypothalamus-pituitary axis and autonomic system were estimated. Plasma leptin concentration (natural logarithm transformed) was significantly and positively (r=0.222, p<0.001) associated with fatigue score, and significantly (p<0.001) higher in the moderately-fatigued group (2.32±0.75ng/ml, mean±SD, n=52) than in the normally-fatigued group (1.85±1.02ng/ml, mean±SD, n=295). Multiple logistic regression analysis showed that plasma leptin concentration was significantly and independently associated with a moderately-fatigued condition independent of other factors, including age, gender, presence of diabetes, hypertension, dyslipidemia, alcohol consumption habit, urinary free cortisol, serum high-sensitive CRP concentration, visceral and subcutaneous fat area, apnea/hypopnea index, sleep efficiency, and heart rate variability. Hyperleptinemia may contribute to fatigue severity in patients with cardiovascular risk factors.

Hypothalamic-Pituitary-Adrenal Hypofunction in Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS) as a Consequence of Activated Immune-Inflammatory and Oxidative and Nitrosative Pathways

There is evidence that immune-inflammatory and oxidative and nitrosative stress (O&NS) pathways play a role in the pathophysiology of myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS). There is also evidence that these neuroimmune diseases are accompanied by hypothalamic-pituitary-adrenal (HPA) axis hypoactivity as indicated by lowered baseline glucocorticoid levels. This paper aims to review the bidirectional communications between immune-inflammatory and O&NS pathways and HPA axis hypoactivity in ME/CFS, considering two possibilities: (a) Activation of immune-inflammatory pathways is secondary to HPA axis hypofunction via attenuated negative feedback mechanisms, or (b) chronic activated immune-inflammatory and O&NS pathways play a causative role in HPA axis hypoactivity. Electronic databases, i.e., PUBMED, Scopus, and Google Scholar, were used as sources for this narrative review by using keywords CFS, ME, cortisol, ACTH, CRH, HPA axis, glucocorticoid receptor, cytokines, immune, immunity, inflammation, and O&NS. Findings show that activation of immune-inflammatory and O&NS pathways in ME/CFS are probably not secondary to HPA axis hypoactivity and that activation of these pathways may underpin HPA axis hypofunction in ME/CFS. Mechanistic explanations comprise increased levels of tumor necrosis factor-α, T regulatory responses with elevated levels of interleukin-10 and transforming growth factor-β, elevated levels of nitric oxide, and viral/bacterial-mediated mechanisms. HPA axis hypoactivity in ME/CFS is most likely a consequence and not a cause of a wide variety of activated immune-inflammatory and O&NS pathways in that illness.

Effect of fermented porcine placenta on physical fatigue in mice

The fatigue spreads among the people who live under stressful life and brings about a negative impact on physical function. Here we evaluated the anti-fatigue effects of fermented porcine placenta (FPP) and main constituents, lysine (Lys) and leucine (Leu) with treadmill stress test and forced swimming test (FST) in animal models. The mice were administrated with FPP, Lys, and Leu for 21 days. After treadmill exercise, FPP, Lys, and Leu significantly reduced fatigue-related biochemical parameters, including lactate, lactate dehydrogenase, glucose, creatine kinase, urea nitrogen, cortisol, and pro-inflammatory cytokines, whereas superoxide dismutase activity and glycogen levels were significantly increased by FPP, Lys, and Leu. In the FST, FPP, Lys, and Leu significantly decreased immobility times and up-regulated brain-derived neurotrophic factor expression in brain. Furthermore, FPP, Lys, and Leu significantly decreased production of tumor necrosis factor-α, interleukin (IL)-6, IL-1β, and IL-4 through blockade of caspase-1/nuclear factor-κB pathway in stimulated splenocytes. In addition, FPP, Lys, and Leu significantly promoted proliferation of splenocytes. In conclusion, these findings suggest the potential of FPP as a novel functional food for the regulation of fatigue.

Hypothalamus-Pituitary-Adrenal Axis Hypersuppression Is Associated with Gastrointestinal Symptoms in Major Depression

Background/Aims

Gastrointestinal symptoms and hypothalamus-pituitary-adrenal (HPA) axis dysfunction are frequently observed in patients with major depression. The primary aim of the study was to investigate the relationship between HPA-axis function and self-perceived functional gastrointestinal symptoms in major depression.

Methods

Patients with major depression (n = 73) and controls representative of the general population (n = 146) underwent a weight-adjusted very low dose dexamethasone suppression test (DST). Patients and controls completed the gastrointestinal symptom rating scale-iritable bowel syndrome (GSRS-IBS) and the hospital anxiety depression scale. Medical records of the patients were screened over a ten year period for functional gastrointestinal disorder and pain conditions.

Results

Patients with high GSRS-IBS scores (above median) exhibited HPA-axis hypersuppression more often than controls (defined by the lowest 10% cutoff of the post-DST cortisol values among controls, adjusted OR 7.25, CI 1.97–26.7) whereas patients with low GSRS-IBS scores did not differ from controls concerning their post-DST cortisol values. Patients who had consulted primary care for functional gastrointestinal disorder (P = 0.039), lumbago (P = 0.006) and chronic multifocal pain (P = 0.057) also exhibited an increased frequency of hypersuppression.

Conclusions

HPA-axis hypersuppression is associated with functional gastrointestinal symptoms in patients with major depression.

The role of the hippocampus in the pathogenesis of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a severe acquired illness characterized by a profound sensation of fatigue, not ameliorated by rest and resulting in a substantial decrease in the amount and quality of occupational, social and recreational activities. Despite intense research, the aetiology and pathogenesis of ME/CFS is still unknown and no conclusive biological markers have been found. As a consequence, an accepted curative treatment is still lacking and rehabilitation programmes are not very effective, as few patients recover. Increased knowledge of the mechanisms leading to the emergence and maintenance of the illness is called for. In this study, I will put forth an alternative hypothesis to explain some of the pathologies associated with ME/CFS, by concentrating on one of the major strategic organs of the brain, the hippocampus. I will show that the ME/CFS triggering factors also impact the hippocampus, leading to neurocognitive deficits and disturbances in the regulation of the stress system and pain perception. These deficits lead to a substantial decrease in activity and to sleep disorders, which, in turn, impact the hippocampus and initiate a vicious circle of increased disability.

Impact of IL-1 inhibition on fatigue associated with autoinflammatory syndromes

Cryopyrin-associated periodic syndromes (CAPS) is a rare group of autoinflammatory disorders that includes familial cold autoinflammatory syndrome or FCAS, Muckle-wells syndrome or MWS, and neonatal-onset multisystem inflammatory disease or NOMID. CAPS is caused by a mutation in the NOD-like receptor family, pyrin domain containing 3 (NLRP3) gene. This ultimately leads to increased production of interleukin (IL)-1β. IL-1β is a biologically active member of the IL-1 family. It is not only a pro-inflammatory cytokine responsible for features such as fever, rash, and arthritis, but is also a major mediator in the central pathways of fatigue. Fatigue is a major component of CAPS and is associated with severely compromised quality of life. In clinical studies, fatigue was measured using functional assessment of chronic illness therapy-fatigue or FACIT-F and short form-36 or SF-36, physical component score instruments. These questionnaires can also be used to monitor improvement of fatigue following initiation of therapy. IL-1 inhibitors block the IL-1 signaling cascade, thereby preventing systemic inflammation in CAPS. The decrease in systemic inflammation is accompanied by improvement in fatigue.