Pharmacological approaches to the therapy of chronic fatigue syndrome

Although a variety of pharmacological agents have been used to treat patients with chronic fatigue syndrome none has been shown to effect a complete resolution of symptoms. Data obtained from a retrospective study and from an objective assessment of the aerobic work capacity of patients with this disorder suggest that the underlying pathophysiological abnormality is a disorder of sleep regulation. This results not only in profound fatigue and lethargy but also reduced sensory threshold for pain, disordered temperature regulation, cardiovascular abnormalities, disturbed higher cerebral function and mental depression. Drugs which modulate sleep, such as tricyclic antidepressants, have a limited effect in improving the symptoms that CFS patients experience. We suggest that other agents which affect central nervous system neurotransmitters, particularly serotonin, may have potential in the management of this condition and need to be evaluated in large controlled clinical trials.

Teaching basic life support to school children using medical students and teachers in a 'peer-training' model--results of the 'ABC for life' programme

BACKGROUND

The 'ABC for life' programme was designed to facilitate the wider dissemination of basic life support (BLS) skills and knowledge in the population. A previous study demonstrated that using this programme 10-12-year olds are capable of performing and retaining these vital skills when taught by medical students. There are approximately 25,000 year 7 school children in 900 primary schools in Northern Ireland. By using a pyramidal teaching approach involving medical students and teachers, there is the potential to train BLS to all of these children each year.

AIMS

To assess the effectiveness of a programme of CPR instruction using a three-tier training model in which medical students instruct primary school teachers who then teach school children.

SETTINGS

School children and teachers in the Western Education and Library Board in Northern Ireland.

METHODS

A course of instruction in cardiopulmonary resuscitation (CPR)--the 'ABC for life' programme--specifically designed to teach 10-12-year-old children basic life support skills. Medical students taught teachers from the Western Education and Library Board area of Northern Ireland how to teach basic life support skills to year 7 pupils in their schools. Pupils were given a 22-point questionnaire to assess knowledge of basic life support immediately before and after a teacher led training session.

RESULTS

Children instructed in cardiopulmonary resuscitation using this three-tier training had a significantly improved score following training (57.2% and 77.7%, respectively, p<0.001).

CONCLUSION

This study demonstrates that primary school teachers, previously trained by medical students, can teach BLS effectively to 10-12-year-old children using the 'ABC for life' programme.

The ‘ABC for life’ programme—Teaching basic life support in schools

BACKGROUND

Less than 1% of the general public know how to assess or manage someone who has collapsed. It has been estimated that if 15-20% of the population were capable of performing cardiopulmonary resuscitation (CPR), mortality of out of hospital cardiac arrest could be decreased significantly. Training basic life support (BLS) skills to school children would be the most cost effective way of achieving this goal and ensuring that a large proportion of the population acquire basic life saving skills.

AIMS

To assess retention of knowledge of basic life support 6 months after a single course of instruction in cardiopulmonary resuscitation designed specifically for school children.

SETTING

School pupils in a rural location in one region of the United Kingdom.

METHODS

A course of instruction in cardiopulmonary resuscitation - the 'ABC for life' programme - specifically designed to teach 10-12-year-old school children basic life support skills. The training session was given to school pupils in a rural location in Northern Ireland. A 22 point questionnaire was used to assess acquisition and retention of basic life support knowledge.

RESULTS

Children instructed in cardiopulmonary resuscitation showed a highly significant increase in level of knowledge following the training session. While their level of knowledge decreased over a period of 6 months it remained significantly higher than that of a comparable group of children who had never been trained.

CONCLUSION

A training programme designed and taught as part of the school curriculum would have a significant impact on public health.

The impact of curricular change on medical students' knowledge of anatomy

BACKGROUND

In recent years, following the publication of Tomorrow's Doctors, the undergraduate medical curriculum in most UK medical schools has undergone major revision. This has resulted in a significant reduction in the time allocated to the teaching of the basic medical sciences, including anatomy. However, it is not clear what impact these changes have had on medical students' knowledge of surface anatomy.

AIM

This study aimed to assess the impact of these curricular changes on medical students' knowledge of surface anatomy.

SETTING

Medical student intakes for 1995-98 at the Queen's University of Belfast, UK.

METHODS

The students were invited to complete a simple examination paper testing their knowledge of surface anatomy. Results from the student intake of 1995, which undertook a traditional, 'old' curriculum, were compared with those from the student intakes of 1996-98, which undertook a new, 'systems-based' curriculum. To enhance linear response and enable the use of linear models for analysis, all data were adjusted using probit transformations of the proportion (percentage) of correct answers for each item and each year group.

RESULTS

The student intake of 1995 (old curriculum) were more likely to score higher than the students who undertook the new, systems-based curriculum.

CONCLUSION

The introduction of the new, systems-based course has had a negative impact on medical students' knowledge of surface anatomy.

Hereditary angioedema precipitated by estrogen replacement therapy in a menopausal woman

We report the first documented case in the literature of hereditary angioedema presenting after commencement of estrogen replacement therapy for menopausal symptoms. The late presentation of the disease and the precipitation of attacks by physiological doses of estrogen replacement therapy make this a highly unusual case. The pathophysiology of hereditary angioedema and its hormonal links are discussed.

Systemic vasculitis and aneurysm formation in the Wiskott-Aldrich syndrome

A 24 year old male who suffered from the Wiskott-Aldrich syndrome developed intra-abdominal bleeding on two occasions. Radiological investigations showed aneurysmal dilatation of branches of the hepatic and superior mesenteric arteries. The second abdominal bleed necessitated laparotomy and the bleeding was localised to the kidneys. Right nephrectomy was performed and histological examination showed a necrotising vasculitis, mainly involving medium and small sized renal blood vessels. Steroids, immunosuppressive treatment, and control of blood pressure resulted in resolution of the vasculitic process and prevented further haemorrhage. Vasculitis and aneurysm formation are rarely described complications of Wiskott-Aldrich syndrome and may account for the life threatening haemorrhage which occurs in this condition.

Chronic fatigue syndrome: Its cause and a strategy for management

This article describes the features of chronic fatigue syndrome and, by analysis of the many clinical paradoxes which it manifests, attempts to give a unifying explanation of the cause of the disorder and a strategy for management.

Diagnosis and carrier detection of chronic granulomatous disease in five families by flow cytometry

BACKGROUND

The application of flow cytometric assays, for determination of phagocyte respiratory burst (ROB) activity, to the investigation of chronic granulomatous disease (CGD) may lead to improved laboratory detection of patients and carriers and indicate the nature of the molecular defect. To evaluate the diagnostic capability of flow cytometry an investigation of 5 CGD families was undertaken.

METHODS

Phorbol myristate acetate (PMA)-induced neutrophil ROB was determined using dihydrorhodamine 123 (DHR) and flow cytometric analysis in 26 members of 5 CGD families (2: X-CGD; 3: autosomal recessive CGD).

RESULTS

Neutrophils from X-CGD patients displayed absence of reactivity. Female carriers demonstrated dual fluorescence peaks of high and low intensity indicative of normal and abnormal populations, respectively. Normal ROB activity was observed in a boy whose X-CGD was successfully treated by bone marrow transplantion. Reduced ROB activity was observed in 3 patients with autosomal-recessive CGD compared with their parents and siblings. The patterns of flow cytometric reactivity correlated with the different molecular defects identified. Absence of the p22phox membrane component of the NADPH oxidase complex resulted in a significantly reduced level of respiratory burst activity which was comparable to that observed in X-CGD, whereas reduced but detectable levels of respiratory burst activity were observed in a patient with diminished levels of p22phox and in a patient with deficiency of the cytosolic p47phox component.

CONCLUSIONS

The DHR flow cytometric assay offers a sensitive diagnostic screening test for CGD and furthermore may provide an indication of the likely underlying molecular defect.

Colitis complicating chronic granulomatous disease. A clinicopathological case report

BACKGROUND

This report concerns a female patient now aged 24 years, diagnosed at the age of 7 years as suffering from chronic granulomatous disease. At age 20 she developed diarrhoea accompanied by rectal bleeding. Endoscopy showed extensive colitis. She failed to respond to medical treatment and underwent total colectomy two years later.

AIMS

To discuss the histological changes in the colon in chronic granulomatous disease.

RESULTS

There was extensive mucosal inflammation throughout colon and rectum resembling ulcerative colitis. In addition characteristic large pigmented macrophages were distributed in the basal mucosa and superficial submucosa. Similar cells accompanied by granulomata were present in mesenteric lymph nodes.

CONCLUSIONS

Colitis is an unusual clinical manifestation of chronic granulomatous disease but the presence and characteristic distribution of such pigmented macrophages in colonic biopsy in children and young adults may suggest the diagnosis.

Normal red cell magnesium concentrations and magnesium loading tests in patients with chronic fatigue syndrome

Red blood cell magnesium concentrations were measured in samples from 89 patients who fulfilled the diagnostic criteria for chronic fatigue syndrome and the results compared to those found in an age and sex matched group selected from the normal population. No significant difference was found. Six patients were further investigated using a magnesium loading test to determine if there was any evidence of magnesium deficiency associated with this disorder. None was found. There is therefore no indication for the use of magnesium therapy in the management of this condition.

'Strawberry gums'--a case of Wegener's granulomatosis

We report a case of Wegener's granulomatosis (WG), localised to the upper aerodigestive tract, which presented as an unusual form of hyperplastic gingivitis in a 36-year-old female. The clinical, serological and histopathological findings are described. The resemblance of the affected gums to over-ripe strawberries is emphasised, in order to draw attention to this characteristic oral manifestation of a rare and potentially life-threatening condition. The response to co-trimoxazole as sole therapy is noted.

Strawberry gums: a clinicopathological manifestation diagnostic of Wegener's granulomatosis?

AIMS

To highlight an uncommon but characteristic gingival lesion associated with Wegener's granulomatosis, emphasising the presence of pseudoepitheliomatous hyperplasia, microabscesses, and multinucleate giant cells; and the paucity of the currently accepted histopathological criteria of Wegener's granulomatosis--namely necrosis, vasculitis, and granulomata.

METHODS

The histopathological features of a gingival biopsy specimen from a case of Wegener's granulomatosis limited to the upper aerodigestive tract in a 36 year old woman were compared with those of 14 similar reported cases.

RESULTS

Pseudoepitheliomatous hyperplasia, microabscesses, and multinucleate giant cells were recorded as present in almost all cases of gingival Wegener's granulomatosis. Necrosis, vasculitis, and granuloma formation were present in only a few cases.

CONCLUSIONS

The combination of pseudoepitheliomatous hyperplasia, microabscesses, and multinucleate giant cells in a gingival biopsy specimen from erythematous, swollen gums, clinically resembling over-ripe strawberries, in a patient with a severe systemic upset, is so typical of Wegener's granulomatosis as to be virtually diagnostic. Recognition of this characteristic lesion may aid early diagnosis and treatment in cases where other diagnostic variables are absent.

Fatigue, depression, and social adjustment in chronic fatigue syndrome

The aims of this study were to determine the characteristics and perceived levels of fatigue and the prevalence of depression in children with chronic fatigue syndrome and to assess the effects of illness on schooling and social functioning. Twelve children with chronic fatigue syndrome were compared with a matched group of children with cystic fibrosis and matched healthy controls. Levels of fatigue (fatigue questionnaire), depression (children's depression inventory), and social adjustment (semistructured interview with parents) were compared between groups. Children with chronic fatigue syndrome had significantly higher median scores for physical and mental fatigue and depressive symptomatology than either comparison group and five children scored as depressed on the children's depression inventory. Schooling and social functioning were seriously disrupted. Children with chronic fatigue syndrome reported high levels of fatigue affecting both physical and mental functioning, the association with depression found in adult studies was confirmed, and social adjustment was poor.

Chronic granulomatous disease 100% corrected by displacement bone marrow transplantation from a volunteer unrelated donor

A boy whose chronic granulomatous disease (CGD) manifested in infancy, and whose elder brother had died at 7 years of age, had phagocytes with complete lack of functional cytochrome B-245 and which could not be induced by interferon gamma to achieve adequate staphylococcal killing. He underwent an elective displacement bone marrow transplant from a volunteer unrelated donor at the age of 8 months. This has achieved 100% replacement of the CGD granulocytes by those of the normal volunteer and the boy has since had a normal childhood for 3 years. Six previous transplants for CGD are briefly reviewed and illustrate that the host abnormal marrow must be completely displaced using an adequate dose of busulphan to ensure 100% stable engraftment of the donor's marrow and that this is best done under elective conditions before septic foci and irreversible organ damage have occurred. Criteria need to be developed to identify early those patients likely to have severe morbidity.

CD4 lymphocyte subset abnormalities associated with impaired delayed cutaneous hypersensitivity reactions in patients with X-linked agammaglobulinaemia

Circulating CD4 lymphocyte subset (CD45RA; CD45RO; CD29; Leu8) levels were determined in nine patients with X-linked agammaglobulinaemia (XLA), nine patients with common variable immunodeficiency (CVI) and in 18 age- and sex-matched controls. CD4CD45RO and CD4CD29 cells were significantly lower (P less than 0.01) in the XLA patient group (CD45RO, 15.7 +/- 10.2%; CD4CD29, 32.1 +/- 14.6%) compared with CVI patients (61.8 +/- 25.4%; 60.1 +/- 11.2%) and normal controls (43.7 +/- 22.3%, 54.5 +/- 22.0%). The levels of CD4CD45RA and CD4Leu8 cells were not abnormal in the XLA patient group. No selective reduction in CD4 subsets was observed in the CVI patient group. Delayed cutaneous hypersensitivity testing of five XLA and five CVI patients revealed a significantly reduced response to recall antigens in patients with XLA. This may relate to the deficiency of circulating memory T cells observed in these patients.

Chronic fatigue syndrome

Chronic Fatigue Syndrome appears to represent a spectrum of disorders in which a variety of pathophysiological mechanisms may operate. While the initiating event in the majority of patients is a pyrexial illness, possibly due to enterovirus infection, evidence of persisting infection or inflammatory changes in muscle and/or brain remain unconvincing. CFS patients display a definite reduced aerobic work capacity compared to normal control subjects, but this may reflect a state of deconditioning resulting from prolonged physical inactivity. They also have an altered perception of their level of exertion and premorbid fitness. The characteristic fluctuation in symptoms, with periods of relapses and partial remissions, may indicate that some central disorder of sensory perception is operational. It may be that a primary sleep disorder results in a reduced sensory threshold for afferent stimuli from muscle. This could well account for many of the subjective symptoms which patients experience. Much more research is clearly necessary if we are to achieve a better understanding of this distressing and at present enigmatic disorder.

Treatment of chronic fatigue syndrome

Chronic Fatigue Syndrome is a disorder which is characterised by profound fatigue together with a variety of other subjective clinical features which persist over a prolonged period of time. The aetiology remains at present uncertain and therefore rational therapeutic strategies are difficult to plan. This paper reviews currently used forms of treatment aimed at correcting the possible pathophysiological mechanisms and discusses the problems associated with the management of this condition.

Selective C7 complement deficiency causing recurrent meningococcal infection

We report on two sisters both with complete absence of the 7th component of complement. This congenital immunodeficiency disorder is associated with recurrent bacterial infection, especially that due to Neisseria species. These cases illustrate many of the well-recognised features of this disorder, but in one patient the illness was complicated by infective endocarditis due to N. meningitidis, a feature not previously reported.

Aerobic work capacity in patients with chronic fatigue syndrome

OBJECTIVE

To determine the aerobic work capacity of patients with the chronic fatigue syndrome and compare it with that of two control groups, and to assess the patients' perception of their level of activity before and during illness.

DESIGN

A symptom limited exercise treadmill test with on line gas analysis and blood sampling was used. Subjects were assessed by one investigator, who was blind to the group which they were in.

SETTING

Department of medicine, Royal Victoria Hospital, Belfast.

SUBJECTS

13 Patients (10 women, three men) who fulfilled the diagnostic criteria for chronic fatigue syndrome. Two control groups of similar age, sex, and body weight: 13 normal subjects (10 women, three men) and seven patients (five women, two men) with the irritable bowel syndrome.

MAIN OUTCOME MEASURES

Aerobic work capacity as assessed by several variables such as length of time on treadmill, heart rate, and biochemical measurements; Borg score; and visual analogue scores of perceived level of physical activity.

RESULTS

The patients with the chronic fatigue syndrome had a reduced exercise capacity compared with that of the other subjects, spending a significantly shorter time on the treadmill. They had a significantly higher heart rate at submaximal levels of exertion and at stage III exertion had significantly higher blood lactate concentrations. Using a Borg score, they showed a significantly altered perception of their degree of physical exertion with a mean score of 8.2 compared with 6.6 and 5.3 for the normal subjects and patients with the irritable bowel syndrome respectively. Using a visual analogue scale they indicated that they had a greater capacity for activity before illness than had the patients with the irritable bowel syndrome, but the scores were not significantly different between the two groups. Both groups of patients indicated reduced activity at the time of testing. Normal controls and patients with the irritable bowel syndrome aspired to a greater level of activity than their current level, but the patients with the chronic fatigue syndrome aspired to a level similar to that which they had had before their illness.

CONCLUSIONS

Patients with the chronic fatigue syndrome have reduced aerobic work capacity compared with normal subjects and patients with the irritable bowel syndrome. They also have an altered perception of their degree of exertion and their premorbid level of physical activity.

Wegener's granulomatosis and autoantibodies to neutrophil antigens

We report five cases of Wegener's granulomatosis all of whom had clinical and histological evidence of disease activity at presentation and in whom autoantibodies to neutrophil antigens were detected. This test may prove useful for the diagnosis of this serious condition and help to monitor disease activity during treatment.

Immune response to multiple skin test antigens in haemophiliacs

Using seven skin test antigens the cell-mediated immune response was evaluated in 20 haemophiliacs, 10 human immunodeficiency virus (HIV) antibody-positive and 10 antibody-negative. Response rates were compared with 75 healthy males of similar age range. All haemophiliac patients displayed significant impairment of cell-mediated reactivity to the test antigens; however, there was no apparent correlation with HIV antibody status.

Systemic amyloidosis--three illustrative cases

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Assessment of cell-mediated immunity in a British population using multiple skin test antigens

An in vivo method of assessing the competence of the cell-mediated immune system (Multitest CMI) was used in 200 healthy volunteers (age range 17-88 years). The profile of reactivity to seven individual antigens was determined. A positive reaction was obtained in 96.5% of the subjects who reacted positively to at least one antigen with 78% reacting to two or more antigens. The number of positive responses and the degree of reactivity was significantly reduced in elderly subjects and in females aged 17-65 years. The Multitest CMI system provides a rapid and convenient method of assessing cell-mediated immunity (CMI) in vivo and could have a wide range of applications in the investigation of immunological, infective and neoplastic conditions.

Acquired immune deficiency syndrome in Northern Ireland

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Heart failure associated with infective endocarditis. A review of 40 cases

Thirty one (78%) of 40 consecutive patients (aged 13-79, mean 44 years) with infective endocarditis had congestive heart failure at presentation. Twenty six (65%) had had rheumatic heart disease and 17 (43%) patients had prosthetic valves. Eight (20%) patients had undergone dental procedures within three months of presentation. Blood cultures were positive in only 22 (55%) of the patients. In nine (41%) of them streptococci of the viridans group were isolated and in seven (32%) patients endocarditis was due to Staphylococcus aureus. Eight patients had Q fever endocarditis. Sixteen patients required operation because of haemodynamic deterioration while they were in hospital; 11 patients had native valves and five had prosthetic valves. Seven had emergency operations and were pyrexial at that time. Four of the seven died in hospital. Of the 12 who were alive and well after surgery only two required further surgery two and three years after the initial operation. Twelve (30%) of the 40 patients died in hospital; in 10 death was mainly due to left ventricular failure or congestive heart failure. All patients died who had renal failure (four cases), myocardial infarction (two cases), complete heart block (one case), or ventricular fibrillation (two cases) before operation. Six (33%) of the 18 patients with culture negative endocarditis died. Two of the four patients seen and treated more than 12 weeks after the onset of symptoms died, as did three of the five patients with prosthetic valves who required surgery while in hospital. Three patients with neurological complications survived and only two (29%) of the seven patients with blood cultures that were positive for Staphylococcus aureus died. Of these 40 high risk patients optimal antibiotic treatment and early surgery for haemodynamic difficulty ensured that 28 (70%) were discharged from hospital alive and well.

Depletion of T-lymphocyte subsets using monoclonal antibody and complement: effect on T-colony formation

Using monoclonal antibody and fresh rabbit serum, mononuclear cells from 11 healthy individuals were depleted of either helper or suppressor T-lymphocytes by complement-mediated lysis. The effect on T-lymphocyte colony formation was studied to determine the nature of the T-colony-forming cell. While depletion of either subset of T-lymphocytes significantly reduced T-colony formation compared to controls (P less than 0.01), colony formation did not differ significantly between helper or suppressor T-cell-depleted cells. Thus T-colony formation appears to be a property of both helper and suppressor T-lymphocytes, and both subsets are necessary for optimal colony formation.

Quantitative and qualitative deficiency of T-lymphocyte colony formation in T-cell lymphoma-leukaemia

T-lymphocyte colony formation in a patient with T-cell lymphoma-leukaemia was found to be defective in three ways. Colony numbers in patient cultures were reduced below those of 20 normal donors. Colony size in patient cultures was uniformly small. Colony formation by patient cells was inhibited in co-cultures of patient and normal cells. These observations indicate that the leukaemic T cells in this rare entity have a defective T-cell function.

Fetal and oncofetal antigens - regulators of immune reactions

This paper proposes the hypothesis that cells which express fetal antigen activate a variety of suppressor mechanisms and thus induce a state of immunological tolerance. Clinical and experimental evidence is cited which supports the hypothesis and indicates that foreign antigens, expressed in association with fetal antigen, are actively tolerated. Thus the fetus, which bears foreign histocompatibility antigens and neoplastic tumours which re-express fetal antigens, fail to evoke appropriate immunological rejection responses, but rather induce a state of active tolerance.

Adult T-cell lymphoma-leukaemia in Blacks from the West Indies

Six Black patients (five born in the West Indies and one in Guyana), aged 21-55 years, had adult T-cell lymphoma-leukaemia diagnosed in the U.K. This disorder is rare in Europe and the U.S.A., but is more common in Japan. Five patients had severe hypercalcaemia which correlated with disease activity, although osteolytic lesions were found in only one. Other clinical features were lymphadenopathy and a high white blood-cell count (range 27-67 X 10(9)/l) with a predominance of pleomorphic lymphoid cells with pronounced nuclear irregularities prominent at ultrastructural level. The cells in all cases formed rosettes with sheep red blood-cells and lacked terminal transferase. Analysis with OKT monoclonal antibodies in four cases confirmed a mature T-cell phenotype defined as helper/inducer (T4+, T6-, T8-) in three. Combination chemotherapy resulted in short-lived remissions; four patients died and two have survived 3-6 months. The disease in these patients is indistinguishable on clinical and pathological grounds from adult T-cell leukaemia/lymphoma in Japan. Geographical clustering among certain racial groups suggests common aetiological factors in the pathogenesis of this disease. The finding of high titre antibody against the structural core protein (p24) of a new human C-type leukaemia virus (human T-cell leukaemia/lymphoma virus) in all tested cases from this series and data from all but one case from Japan suggest that one such factor may be viral.