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[Return to digest index] --------------------------------------------- This is a special digest of Co-Cure Research & Medical posts only Problems? Write to mailto:email@example.com --------------------------------------------- ---------------------------------------------------------------------- Date: Tue, 5 Jun 2007 08:21:53 -0700 From: Melissa O'Toole <m_otoole2 YAHOO.COM> Subject: NOT,RES: William C. Reeves answers a few questions about "Identification of ambiguities in the 1994 CFS research case definition..." ESI Special Topics, November 2006 Citing URL: http://www.esi-topics.com/fmf/2006/november06-WilliamCReeves.html >From •>>November 2006 William C. Reeves answers a few questions about this month's fast moving front in the field of Pharmacology & Toxicology. Field: Pharmacology & Toxicology Article: Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution Authors: Reeves, WC;Lloyd, A;Vernon, SD;Klimas, N;Jason, LA;Bleijenberg, G;Evengard, B;White, PD;Nisenbaum, R;Unger, ER;Int Chronic Fatigue Syndrome Study Journal: BMC HEALTH SERV RES 30 3: art. no.-25, DEC 31 2003 Addresses: Ctr Dis Control & Prevent, Atlanta, GA 30333 USA. Ctr Dis Control & Prevent, Atlanta, GA 30333 USA. Univ New S Wales, Sch Pathol, Inflammat Res Unit, Sydney, NSW, Australia. Univ Miami, Miami, FL 33152 USA. Dept Vet Affairs Med Ctr, Miami, FL USA. Depaul Univ, Chicago, IL 60604 USA. Univ Med Ctr Nijmegen, Nijmegen, Netherlands. Huddinge Univ Hosp, Karolinska Inst, Stockholm, Sweden. Barts & London Sch Med, London, England. Why do you think your paper is highly cited? This represents the key methodology paper in the field. The high citation rate reflects international acceptance of the paper’s concept and increasing scientific interest in chronic fatigue syndrome (CFS). The 1994 CFS case definition (Fukuda et al., "The chronic fatigue syndrome: a comprehensive approach to its definition and study," Ann. Int. Med. 121:953-959, 1994—1,110 citations recorded by ISI Web of Knowledge) represented the first international consensus definition for the illness. However, in spite of wide acceptance, there has been a lack of consensus in the findings of many well-conducted studies both within and between centers. This reflects the lack of a common methodology to apply criteria of the case definition. The 2003 paper specifies standardized and validated criteria for measuring the clinical dimensions of CFS (impairment, fatigue, and accompanying symptoms) and puts the weight of the International Chronic Fatigue Syndrome Study Group behind the recommendations. Any investigator in the field needs to consider and cite this paper to be considered for peer review. The paper is particularly important for the pharmaceutical industry because it provides standard methods to monitor the clinical course of CFS and response to therapy. Does it describe a new discovery, methodology, or synthesis of knowledge? An international collaborative group of experienced investigators met (in 2000, 2001, and 2002) for a series of 3-day workshops to identify and discuss problems in application of the 1994 CFS case definition. This paper that resulted from the deliberations represents a synthesis of evolving knowledge in the field. Could you summarize the significance of your paper in layman’s terms? CFS is defined by symptoms and disability, has no diagnostic physical signs or laboratory abnormalities, and its causes and pathology remain unknown. So, diagnosis is based on self-reported symptoms and ruling out treatable medical and psychiatric causes, and treatment is aimed at relieving symptoms rather than a cure. Research has been constrained by ambiguities in the case definition. When this happens it is difficult to compare different findings because different subgroups of patients have been studied. In essence, one investigator is studying apples, the next oranges. In this paper, an international group came together to reach an agreement on exactly what the case definition means, agree on exclusion criteria, and agree to use comparable measures to define CFS. Since this paper came out, nearly every study of CFS has relied on the criteria it describes. Investigators can now compare apples to apples. Moreover, many of the recommendations are useful for health care providers (and their patients) because they specify standardized measures of the symptoms and disability associated with CFS. How did you become involved in this research, and were there obstacles along the way? CFS is a U.S. Department of Health and Human Services priority and the Centers for Disease Control and Prevention (CDC) is responsible for public health research to control the illness. The CDC has been involved in CFS research since the illness was first recognized as a public health problem and has been the international leader in developing diagnostic criteria. The primary obstacle has been lack of medical and public acceptance of CFS as a valid illness. Are there any social or political implications for your research? Every illness has societal and political implications. Between one and four million Americans suffer CFS, half have been ill for at least seven years, a quarter of those with the illness are unemployed or receiving disability, and the average affected family forgoes approximately $20,000 in annual earnings and wages. Yet, fewer than 20% of those afflicted have received medical care for CFS. Despite more than 3,000 articles in the peer-reviewed medical literature, the pathophysiology of CFS is not well understood. There are no diagnostic laboratory abnormalities or clinical tests. There is no public health control or prevention strategy for CFS. This paper helps to resolve some of the research obstacles related to classification, provides investigators and clinicians tools with which to evaluate the clinical course and response to treatment, gives peer reviewers clearer guidelines, and removes some of the obstacles for funding.End William C. Reeves, MD, MSc Chief of the Chronic Viral Diseases Branch Coordinating Center for Infectious Diseases U.S. Centers for Disease Control and Prevention Atlanta, GA, USA [Return to top] ------------------------------ Date: Tue, 5 Jun 2007 11:42:24 -0400 From: Fred Springfield <fredspringfield VERIZON.NET> Subject: RES: The Experience of Cancer-Related Fatigue and Chronic Fatigue Syndrome: A Qualitative and Comparative Study The Experience of Cancer-Related Fatigue and Chronic Fatigue Syndrome: A Qualitative and Comparative Study Journal: J Pain Symptom Manage. 2007 May 31; [Epub ahead of print] Authors: Bennett B, Goldstein D, Friedlander M, Hickie I, Lloyd A. Affiliations: Department of Medical Oncology (B.B., D.G., M.F.), Prince of Wales Hospital, Sydney, Australia, The Brain and Mind Research Institute (I.H.), University of Sydney, Australia, and the School of Medical Sciences (A.L.), University of New South Wales, Sydney Australia. NLM Citation: PMID: 17544246 Cancer-related fatigue (CRF) is a common and disabling symptom complex reported by survivors. This study aimed to better understand the manifestations of CRF in women treated for breast cancer, and to compare them with those of women diagnosed with chronic fatigue syndrome (CFS). Women with CRF persisting 6 months after treatment for early stage breast cancer, and women with CFS participated in separate, audiotaped focus groups. Transcripts of the sessions were analyzed using the NUD*IST software, and interpreted using grounded theory. Twenty-eight women participated, 16 with CRF and 12 with CFS. Analysis of transcripts from both groups revealed a similar core set of symptoms, featuring fatigue, neurocognitive difficulties, and mood disturbances. Women with CFS reported additional symptoms including musculoskeletal pain and influenza-like manifestations. Both groups suffered disabling behavioral consequences of the symptom complex. Qualitatively, CRF appears closely related to CFS. These findings raise the emergent hypothesis of a conserved neurobehavioral symptom complex, which results from diverse triggering insults. [Return to top] ------------------------------ Date: Tue, 5 Jun 2007 14:01:29 -0400 From: Fred Springfield <fredspringfield VERIZON.NET> Subject: RES: Longitudinal analysis of pro- and anti-inflammatory cytokine production in severely fatigued adolescents Longitudinal analysis of pro- and anti-inflammatory cytokine production in severely fatigued adolescents. Journal: Brain Behav Immun. 2007 May 31; [Epub ahead of print] Authors: Ter Wolbeek M, van Doornen LJ, Kavelaars A, van de Putte EM, Schedlowski M, Heijnen CJ. Affiliations: Laboratory of Psychoneuroimmunology, University Medical Center Utrecht, Room: KC03.068.0, P.O. Box 85090, 3508 AB Utrecht, The Netherlands; Department of Health Psychology, Utrecht University, P.O. Box 80140, 3508 TC Utrecht, The Netherlands. NLM Citation: PMID: 17544255 In the adolescent population, fatigue is associated with somatic complaints, unrefreshing sleep, cognitive disturbances and symptoms of depression and anxiety. This pattern of symptoms resembles the one described in chronic fatigue syndrome (CFS). Since immunological alterations have been reported in CFS patients, we wondered whether also severely fatigued girls from a healthy population would show comparable alterations in psychological and immunological parameters. We tested this hypothesis in a longitudinal design, allowing a reliable assessment of the participants' characteristic immune status. Groups of severely fatigued (N=67) and non-fatigued (N=61) participants were selected. Severely fatigued girls reported more depressive symptoms, anxiety, reduced sleep quality, and somatic and CFS-related symptoms than non-fatigued participants across three measurements during one year (T1: spring, T2: autumn, T3: spring). In contrast, no group differences in mitogen-induced cytokine production or T-cell proliferation in vitro or in leukocyte subset counts were observed. Although absolute cytokine production and cell counts were affected by seasonal variation, the within-subject values, relatively to the rest of the participants, were fairly stable. Data from a small group of CFS patients (N=11) showed similarities in self-reported complaints between CFS patients and fatigued participants. Interestingly, CFS patients showed a distinct immune profile when compared to the severely fatigued or non-fatigued participants, i.e. increased levels of anti-inflammatory cytokines (IL-10, decreased IFN-gamma/IL-10 ratio) and reduced levels of pro-inflammatory cytokines (IL-6, TNF-alpha) over all three time points analyzed. These results show that, although overlap in symptomatology between the general population and patients with CFS was observed, only CFS patients show a skewing of the cytokine balance towards an anti-inflammatory profile. [Return to top] ------------------------------ Date: Tue, 5 Jun 2007 14:54:05 -0400 From: "Bernice A. Melsky" <bernicemelsky VERIZON.NET> Subject: RES: Double-blind, multicenter trial comparing acetyl l-carnitine with placebo in the treatment of fibromyalgia patients Double-blind, multicenter trial comparing acetyl l-carnitine with placebo in the treatment of fibromyalgia patients. Clin Exp Rheumatol. 2007 Mar-Apr;25(2):182-8. Rossini M, Di Munno O, Valentini G, Bianchi G, Biasi G, Cacace E, Malesci D, La Montagna G, Viapiana O, Adami S. Rheumatology Unit, University of Verona, Italy. PMID: 17543140 OBJECTIVE: Fibromyalgia (FMS) is a chronic syndrome characterized by widespread pain, troubled sleep, disturbed mood, and fatigue. Several analgesic strategies have been evaluated but the results are moderate and inconsistent. Antidepressant agents are now considered the treatment of choice in most patients. It has been recently suggested that FMS may be associated with metabolic alterations including a deficit of carnitine. In this multicenter randomized clinical trial we evaluated the efficacy of acetyl L-carnitine (LAC) in patients with overt FMS. METHODS: One hundred and two patients meeting the American College of Rheumatology criteria for FMS were randomized into the study. The treatment consisted of 2 capsules/day of 500 mg LAC or placebo plus one intramuscular (i.m.) injection of either 500 mg LAC or placebo for 2 weeks. During the following 8 weeks the patients took 3 capsules daily containing either 500 mg LAC or placebo. The patients were seen during treatment after 2 (visit 3), 6 (visit 4) and 10 weeks (visit 5). The patients were also visited 4 weeks after treatment discontinuation (follow-up visit). Outcome measures included the number of positive tender points, the sum of pain threshold (kg/cm<sup>2</sup> or "total myalgic score"), the Short Form 36 (SF36), a 100 mm visual analog scale (VAS) for self-perceived stiffness, fatigue, tiredness on awakening, sleep, work status, depression, and muscular-skeletal pain, and the Hamilton depression scale. RESULTS: The "total myalgic score" and the number of positive tender points declined significantly and equally in both groups until the 6th week of treatment. At the 10th week both parameters remained unchanged in the placebo group but they continued to improve in the LAC group with a statistically significant between-group difference. Most VAS scores significantly improved in both groups. A statistically significant between-group difference was observed for depression and musculo-skeletal pain. Significantly larger improvements in SF36 questionnaire were observed in LAC than in placebo group for most parameters. Treatment was well-tolerated. CONCLUSION: Although this experience deserves further studies, these results indicate that LAC may be of benefit in patients with FMS, providing improvement in pain as well as the general and mental health of these patients. [Return to top] ------------------------------ Date: Wed, 6 Jun 2007 15:00:03 -0400 From: "Bernice A. Melsky" <bernicemelsky VERIZON.NET> Subject: RES: Cytokine patterns in fibromyalgia and their correlation with clinical manifestations Cytokine patterns in fibromyalgia and their correlation with clinical manifestations. Clin Exp Rheumatol. 2007 Mar-Apr;25(2):225-30. Bazzichi L, Rossi A, Massimetti G, Giannaccini G, Giuliano T, De Feo F, Ciapparelli A, Dell'osso L, Bombardieri S. Department of Internal Medicine, Division of Rheumatology, University of Pisa, Pisa, Italy. PMID: 17543146 OBJECTIVE: To examine the possible role of the soluble factor in fibromyalgia (FM) by studying the correlation of cytokine levels with the patients' clinical and psychiatric profile. METHODS: Eighty FM patients underwent clinical and psychiatric evaluations, and plasma levels of cytokines (IL-1, IL-6, IL-8, IL-10, TNF-alpha), aspecific markers of inflammation, rheumatoid factor (RF), anti-extractable nuclear antigen (ENA) antibodies, and anti-nuclear factor (FAN) were measured. RESULTS: Higher levels of IL-10, IL-8 and TNF-alpha were found in FM patients than in controls. Significant correlations between the biochemical parameters and clinical data were found. CONCLUSION: The higher levels of cytokines found in FM patients suggest the presence of an inflammatory response system (IRS) and highlight a parallel between the clinical symptoms and biochemical data. They support the hypothesis that cytokines may play a role in the clinical features of fibromyalgia. In addition, the similar cytokine patterns found in FM patients with different psychiatric profiles suggests that IRS impairment may play a specific role in the disease. [Return to top] ------------------------------ Date: Wed, 6 Jun 2007 15:04:58 -0400 From: "Bernice A. Melsky" <bernicemelsky VERIZON.NET> Subject: RES: Fibromyalgia: revisiting the literature Fibromyalgia: revisiting the literature. JCCA J Can Chiropr Assoc. 2004 Jun;48(2):119-31. Forbes D, Chalmers A. Private practice, Vancouver, British Columbia. PMID: 17549223 Fibromyalgia has a distinct clinical presentation. With no distinct characteristic beyond the presence of 11 or more tender points and chronic pain in all four quadrants of the body, it represents one extreme of a normal distribution of pain states. Research exploration utilizing the ACR criteria has not found solid empirical evidence to link the finding of multiple tender points to a specific pathological process. These points may be present as a concomitant finding with psychological disease states but they have not lead to further etiological understanding. Measurement of outcomes is difficult and the prognosis for patients in the specialty care setting is poor, however in the general population the prognosis is variable, and includes improvement without treatment. The success of treatments has been limited mainly to helping patients improve their ability to cope with, but not to eliminate the tender points. [Return to top] ------------------------------ Date: Thu, 7 Jun 2007 15:08:02 -0400 From: "Bernice A. Melsky" <bernicemelsky VERIZON.NET> Subject: RES: Effectiveness of Massage Therapy for Chronic, Non-malignant Pain: A Review Effectiveness of Massage Therapy for Chronic, Non-malignant Pain: A Review. Evid Based Complement Alternat Med. 2007 Jun;4(2):165-79. Epub 2007 Feb 5. Tsao JC. Pediatric Pain Program, Department of Pediatrics, David Geffen School of Medicine at UCLA, USA. PMID: 17549233 Previous reviews of massage therapy for chronic, non-malignant pain have focused on discrete pain conditions. This article aims to provide a broad overview of the literature on the effectiveness of massage for a variety of chronic, non-malignant pain complaints to identify gaps in the research and to inform future clinical trials. Computerized databases were searched for relevant studies including prior reviews and primary trials of massage therapy for chronic, non-malignant pain. Existing research provides fairly robust support for the analgesic effects of massage for non-specific low back pain, but only moderate support for such effects on shoulder pain and headache pain. There is only modest, preliminary support for massage in the treatment of fibromyalgia, mixed chronic pain conditions, neck pain and carpal tunnel syndrome. Thus, research to date provides varying levels of evidence for the benefits of massage therapy for different chronic pain conditions. Future studies should employ rigorous study designs and include follow-up assessments for additional quantification of the longer-term effects of massage on chronic pain. [Return to top] ------------------------------ Date: Thu, 7 Jun 2007 15:15:45 -0400 From: "Bernice A. Melsky" <bernicemelsky VERIZON.NET> Subject: RES: The Impact of Increased Body Mass Index on Systemic Lupus Erythematosus: Data From LUMINA, a Multiethnic Cohort The Impact of Increased Body Mass Index on Systemic Lupus Erythematosus: Data From LUMINA, a Multiethnic Cohort. J Clin Rheumatol. 2007 Jun;13(3):128-133. Chaiamnuay S, Bertoli AM, Fernández M, Apte M, Vilá LM, Reveille JD, Alarcón GS; for the LUMINA Study Group. From the *Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama; †Department of Medicine, Division of Rheumatology, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico; ‡Department of Medicine, Division of Rheumatology, University of Texas Health Science Center at Houston, Houston, Texas. PMID: 17551377 OBJECTIVE: The aim of this study was to examine the impact of an increased body mass index (BMI) on disease activity, damage accrual, fatigue, self-reported health-related quality of life (HRQOL), and fibromyalgia in patients with lupus using longitudinal data from LUMINA, a large multiethnic cohort. METHODS: SLE patients (>/=4 ACR revised criteria), </=5 years disease duration at entry into the cohort (T0), of Hispanic (from Texas or from the Island of Puerto Rico), African American, or white ethnicity were included. BMI was ascertained at T0 or first recorded. The average scores from all visits for disease activity (SLAM-R), self-reported HRQOL (physical and mental component summary measures of the SF-36) and fatigue (Fatigue Severity Scale), the score at last visit for damage accrual (SLICC Damage Index), and fibromyalgia (ACR criteria), if present at any visit, were examined for their association with an increased BMI by univariable and multivariable analyses. RESULTS: Three-hundred sixty-four patients were included; 28% were obese (BMI >/=30 kg/m). An increased BMI was associated with older age, less social support, higher degree of helplessness, depression, more abnormal illness-related behaviors, poorer self-reported HRQOL, fatigue, and fibromyalgia, but not with disease activity or damage accrual by univariable analyses. In multivariable analyses, BMI was independently associated with fibromyalgia but not with disease activity, fatigue, or self-reported HRQOL. CONCLUSIONS:: An increased BMI is independently associated with presence of fibromyalgia but not with disease activity, damage accrual, fatigue or self-reported quality of life in patients with SLE. Optimizing weight merits investigation to see if it can significantly impact this pervasive SLE-associated manifestation. [Return to top] ------------------------------ Date: Thu, 7 Jun 2007 15:23:16 -0400 From: "Bernice A. Melsky" <bernicemelsky VERIZON.NET> Subject: RES: Self-assessed pain intensity and disability in subjects diagnosed with fibromyalgia claiming retirement pension [Self-assessed pain intensity and disability in subjects diagnosed with fibromyalgia claiming retirement pension.] [Article in German] Schmerz. 2007 Jun 6; [Epub ahead of print] Häuser W. Zentrum für Schmerztherapie/Medizinische Klinik I (Gastroenterologie, Hepatologie, Stoffwechsel- und Infektionskrankheiten, Psychosomatik), Klinikum Saarbrücken gGmbH, Winterberg 1, 66119, Saarbrücken, Deutschland, firstname.lastname@example.org. PMID: 17551757 INTRODUCTION: The clinical experience that subjects claiming retirement pension tend to aggravate their symptoms in psychometric tests has not yet, to our knowledge, been empirically tested. METHODS: Pain intensities and the summary score of the Pain Disability Index (PDI) of 83 consecutive subjects diagnosed with fibromyalgia syndrome (FMS) claiming retirement pension in medical assessment for the German Social Court were compared with 43 consecutive patients diagnosed with FMS of an outpatient pain department who did not claim retirement pension. Moreover, the relative predictive value of claiming retirement pension compared to other potential sociodemographic and clinical predictors of pain intensity and self-assessed disability was determined. RESULTS: Subjects claiming retirement pension within the context of medical testimony stated higher pain intensities and disabilities than patients who did not claim retirement pension (P<0.01 in all cases). Claiming disability pension was an independent predictor of minimum pain intensity (r(2)=0.10, P=0.02), of maximum pain intensity (r(2)=0.16, P=0.002) and of the summary score of the PDI (r(2)=0.08, P=0.008). CONCLUSIONS: The association between claiming retirement pension and high self-assessed pain and disability should be kept in mind in the context of pain therapy as well of medical expertise. [Return to top] ------------------------------ Date: Thu, 7 Jun 2007 18:19:34 -0700 From: Melissa O'Toole <m_otoole2@YAHOO.COM> Subject: MED: Is pain a cause or symptom of depression? >From the June 7, 2007 edition of HEALTHbeat, an electronic publication of the Harvard School of Medicine: Is pain a cause or symptom of depression? Pain is depressing, and depression causes and intensifies pain. People with chronic pain have three times the average risk of developing psychiatric symptoms — usually mood or anxiety disorders — and depressed patients have three times the average risk of developing chronic pain. When low energy, insomnia, and hopelessness resulting from depression or anxiety perpetuate and aggravate physical pain, it can be impossible to tell which came first or where one leaves off and the other begins. Pain slows recovery from depression, and depression makes pain more difficult to treat. For example, depression may cause patients to drop out of pain rehabilitation programs. So it often makes sense to treat both pain and depression; that way they are more likely to recede together. Brain pathways Normally, the brain diverts signals of physical discomfort so that we can concentrate on the external world. When this shut-off mechanism is impaired, physical sensations like pain are more likely to become the center of attention. Brain pathways that handle pain signals use some of the same chemical messengers (neurotransmitters) that are involved in the regulation of mood. When these pathways start to malfunction, pain is intensified, along with sadness, hopelessness, and anxiety. And as chronic pain, like chronic depression, takes root in the nervous system, the problem perpetuates itself. The mysterious disorder known as fibromyalgia may be an example of this kind of biological process linking pain and depression. Its symptoms include widespread muscle pain and tenderness at certain pressure points, with no evidence of tissue damage. Brain scans of people with fibromyalgia show highly active pain centers, and the disorder is more closely associated with depression than most other medical conditions. This leads some experts to speculate that the pain sensitivity and emotional storminess of fibromyalgia result from faulty brain pathways. Treating pain and depression in combination In pain rehabilitation centers, specialists treat both problems together, often with the same techniques, including progressive muscle relaxation, hypnosis, and meditation. Physicians prescribe standard pain medications — acetaminophen, aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDs), and in severe cases, opiates — along with a variety of psychiatric drugs. Almost every drug used in psychiatry can serve as a pain medication. By relieving anxiety, fatigue, or insomnia, these medications also ease related pain. In addition, antidepressants — sometimes given in low doses — may relieve pain in ways unrelated to their antidepressant effects. Exercise and psychotherapy are commonly used at pain centers, too. Physical therapists help patients perform exercises not only to break the vicious cycle of pain and immobility, but also to help relieve depression. Cognitive and behavioral therapies teach pain patients how to avoid fearful anticipation, banish discouraging thoughts, and adjust everyday routines to ward off physical and emotional suffering. Psychotherapy helps demoralized patients and their families tell their stories and describe the experience of pain in its relation to other problems in their lives. [Return to top] ------------------------------ Date: Fri, 8 Jun 2007 14:52:40 -0400 From: Fred Springfield <fredspringfield VERIZON.NET> Subject: RES: The impact of a 4-hour sleep delay on slow wave activity in twins discordant for chronic fatigue syndrome The impact of a 4-hour sleep delay on slow wave activity in twins discordant for chronic fatigue syndrome Journal: Sleep. 2007 May 1;30(5):657-62. Authors: Roseanne Armitage, PhD ; Carol Landis, DNSc, RN ; Robert Hoffmann, PhD ; Martha Lentz, PhD, RN ; Nathaniel F. Watson, MD ; Jack Goldberg, PhD ; Dedra Buchwald, MD  Affiliations:  Department of Psychiatry, University of Michigan, Ann Arbor, MI <rosearmi med.umich.edu>  Departments of Biobehavioral Nursing and Health Systems,  Neurology,  Epidemiology, and  Medicine, University of Washington, Seattle, WA, Work conducted at the University of Washington, Seattle WA. Affiliation: Department of Psychiatry, University of Michigan, Ann Arbor, MI 48105, USA. <rosearmi med.umich.edu> NLM Citation: PMID: 17552382 OBJECTIVES: Chronic fatigue syndrome (CFS) has been associated with altered amounts of slow wave sleep, which could reflect reduced delta electroencephalograph (EEG) activity and impaired sleep regulation. To evaluate this hypothesis, we examined the response to a sleep regulatory challenge in CFS. DESIGN: The first of 3 consecutive nights of study served as laboratory adaptation. Baseline sleep was assessed on the second night. On the third night, bedtime was delayed by 4 hours, followed by recovery sleep. Total available sleep time was held constant on all nights. SETTING: A research sleep laboratory. PARTICIPANTS: 13 pairs of monozygotic twins discordant for CFS. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Power spectral analysis quantified slow wave activity (SWA) in the 0.5-3.9 Hz band in successive NREM periods (stage 2, 3, or 4) on each night. To ensure comparability, analyses were restricted to the first 4 NREM periods on each night. Data were coded for NREM period and twin pair. Repeated-measures analysis of variance (ANOVA) contrasted sleep delay effects across NREM periods between twin pairs. A second ANOVA calculated the SWA in each NREM period in recovery sleep relative to baseline SWA. The 2 groups of twins were similar on baseline SWA power. After sleep delay, CFS twins exhibited significantly less SWA power in the first NREM period of recovery sleep and accumulated a smaller percentage of SWA in the first NREM period than their co-twins. CONCLUSIONS: CFS is associated with a blunted SWA response to sleep challenge, suggesting that the basic sleep drive and homeostatic response are impaired. [Return to top] ------------------------------ Date: Fri, 8 Jun 2007 14:58:58 -0400 From: "Bernice A. Melsky" <bernicemelsky@VERIZON.NET> Subject: RES: A closer look at pain and hepatitis C: Preliminary data from a veteran population A closer look at pain and hepatitis C: Preliminary data from a veteran population. J Rehabil Res Dev. 2007;44(2):231-44. Silberbogen AK, Janke EA, Hebenstreit C. VA Boston Healthcare System, Psychology Service (116B), 150 South Huntington Avenue, Boston, MA 02130. email@example.com. PMID: 17551875 An association between the hepatitis C virus (HCV) and various pain diagnoses, including arthritis, fibromyalgia, and peripheral neuropathy, has been reported. In this article, we review the literature on the relationship between HCV and pain, highlighting current knowledge as well as methodological issues that exist in many studies. We also present preliminary findings from a survey conducted at two Department of Veterans Affairs facilities to assess the scope and impact of pain on functioning in veterans with HCV. Our results indicate that pain is very prevalent within this population and that HCV-positive veterans who experience persistent pain have significant depressive symptoms and engage in high-risk behaviors, such as cigarette smoking and alcohol use. Finally, we draw upon our review and preliminary results to propose areas of future rehabilitative research and to address the implications for clinicians working with patients with comorbid HCV and pain. [Return to top] ------------------------------ Date: Sat, 9 Jun 2007 04:31:20 +0200 From: Jan van Roijen <j.van.roijen CHELLO.NL> Subject: med: ME is a physical condition ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Send an Email for free membership ~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~ >>>> Help ME Circle <<<< >>>> 9 June 2007 <<<< Editorship : j.van.roijen chello.nl Outgoing mail scanned by Norton AV ~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~ From: Stephen Ralph <stephen.e.ralph btinternet.com> FROM THE YOUNG ME SUFFERERS TRUST Disability Now, June 2007 Health News (p 13) 'ME is a physical condition' ~~~~~~~~~~~~~~~~~~~~~~ Campaigners have welcomed new research that appears to show that ME (myalgic encephalomyelitis) is a physical and not a psychiatric condition. The new definition, compiled by ME expert Dr Byron Hyde at the Nightingale Research Foundation in Canada, separates ME from chronic fatigue syndrome (CFS) and defines ME as a brain injury. ME is estimated to affect 250,000 people in the UK, around 10 per cent of whom are children. Symptoms include loss of balance and memory, difficulties speaking and thinking and abnormal sensory perception. Inappropriate treatment can lead to pateints experiencing seizures and paralysis and some may need to be tube-fed. Jane Colby, executive director of The Young ME Sufferers Trust (YMEST), who helped compile the new definition, said: "We desperately need a testable definition which can show up the serious physical disabilities that these children have. "Viral damage to the brain is behind this illness and the Nightingale definition reveals the pattern of damage caused." She added: "You will never get proper diagnosis and treatment [of ME] until it is removed from the umbrella term of CFS." For more information, contact the Trust: tel 01245 401080 or visit: www.tymestrust.org `````````````````````````` Picture: Shannen Dabson, 12, an advocate of The Young ME Sufferers Trust, with her Tymes Trustcard, which helps explain her condition to school staff. ```````````````````````````````````````` Jane Colby Executive Director The Young ME Sufferers Trust PO Box 4347 Stock Ingatestone Essex CM4 9TE www.tymestrust. [Return to top] ------------------------------ Date: Sat, 9 Jun 2007 10:14:49 -0400 From: "John Herd <johnherd JOHNHERD.COM> [via Co-Cure Moderators] Subject: NOT,RES:Is the latest CDC prevalence figure including everything, including the kitchen sink? Is the latest CDC prevalence figure including everything including the kitchen sink? by John Herd johnherd johnherd.com In the CDC's recent article on the prevalence of CFS (1) the CDC estimates that 2.54% of people between the age of 18 and 59 years have CFS. As Dr. Peter White comments in his editorial (2) that translates to 7.5 million afflicted Americans. [And that does not include adolescents afflicted]. Dr. White goes on to point out that the CDC's latest prevalence estimate represents a six to ten fold increase from the CDC's previous prevalence estimate. What causes such a huge increase? The answer most likely is the methods of selection, the CDC's use of a modified case definition and the CDC touted new diagnostic tools being used. In a November 2006 question and answer interview on Essential Science Indicators' web site (3) Dr. Reeves states, "Research has been constrained by ambiguities in the case definition. When this happens it is difficult to compare different findings because different subgroups of patients have been studied. In essence, one investigator is studying apples, the next oranges." Later in the interview he claims that because of an improved CFS diagnostic criteria with "comparable measures" "investigators can now compare apples to apples." It seems that with the CDC new 7.5 million Americans afflicted figure, that they've stepped backwards to not looking at apples and oranges, but the whole food group. Dr. White appears to have similar concern about the CDC's protocols and findings in their latest research. He notes "there were important differences in the method of ascertainment used in the Georgia study that may help to explain the greater prevalence" with "different initial screening question". "Instead of asking whether a household member was suffering from 'fatigue', as previously done, the screening question asked about being 'unwell'"... Next Dr. white speculates whether "comorbid psychiatric conditions may have inflated the [CDC's latest] prevalence." In an English study of ME/CFS, when subjects with comorbid psychiatric conditions were excluded the prevalence figure dropped by 80%. To be fair there is a vast gray zone in which researchers of ME/CFS have had difficult with the subject of identifying between those whom have secondary (reactive) psychological difficulties from the many impacts of having ME/CFS, the actual apples, and those whom have primary psychiatric conditions, some of the oranges. So is the CDC in actuality taking an accuracy step backward in the research of ME/CFS? It seems so since their newest possible 7.5 million prevalence figure may be combining not just apples and oranges but the whole food group. ---------------------- References: 1. William C. Reeves, James F. Jones, Elizabeth Maloney, Christine Heim, David C. Hoaglin, Roumiana S. Boneva, Marjorie Morrissey, Rebecca Devlin, Prevalence of Chronic Fatigue Syndrome in Metropolitan, Urban, and Rural Georgia, Population Health Metrics, www.pophealthmetrics.com 2. Peter D White, How common is chronic fatigue syndrome; how long is a piece of string?, Population Health Metrics 2007, 5:6 doi:10.1186/1478-7954-5-6, www.pophealthmetrics.com 3. Dr. William Reeves, William C. Reeves answers a few questions about this month's fast moving front in the field of Pharmacology & Toxicology, Essential Science Indicators, URL: http://www.esi-topics.com/fmf/2006/november06-WilliamCReeves.htmlhttp://www.esi-topics.com/fmf/2006/november06-WilliamCReeves.html [Return to top] ------------------------------ Date: Sat, 9 Jun 2007 13:34:41 -0400 From: Fred Springfield <fredspringfield VERIZON.NET> Subject: RES: Prevalence of chronic fatigue syndrome in metropolitan, urban, and rural Georgia Prevalence of chronic fatigue syndrome in metropolitan, urban, and rural Georgia Journal: Population Health Metrics 2007, 5:5 doi:10.1186/1478-7954-5-5 Authors: William C. Reeves [1,*], James F. Jones , Elizabeth Maloney , Christine Heim , David C. Hoaglin , Roumiana S. Boneva , Marjorie Morrissey , Rebecca Devlin  Affiliations:  Chronic Viral Diseases Branch, Coordinating Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.  Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA.  Abt Associates Inc, Cambridge, MA, USA,  Abt Associates Inc, Chicago, IL, USA. Published 8 June 2007 Abstract (provisional) Background Chronic fatigue syndrome (CFS) is a debilitating illness with no known cause or effective therapy. Population-based epidemiologic data on CFS prevalence are critical to put CFS in a realistic context for public health officials and others responsible for allocating resources. Methods Based on a random-digit dialing survey we ascertained CFS cases and controls to estimate the prevalence of CFS in metropolitan, urban, and rural populations of Georgia. This report focuses on the 5,623 of 19,381 respondents ages 18 to 59 years old. Fatigued (2,438), randomly selected unwell not fatigued (1,429) and randomly selected well (1,756) respondents completed telephone questionnaires concerning fatigue, other symptoms, and medical history. Subsets of those identified by interview as having CFS-like illness (292), chronic unwellness which was not CFS-like (268--randomly selected), and well subjects (223, matched to those with CFS-like illness on sex, race, and age) completed a clinical evaluation. Results We estimated that 2.54% of persons 18 to 59 years of age suffered from CFS. There were no significant differences in prevalence of CFS between metropolitan, urban or rural populations or between white and black residents of the three regions. However, there were significant differences in female-to-male ratios of prevalence across the strata (metropolitan female : male 11.2 : 1, urban 1.7 : 1, rural 0.8 : 1). Conclusions We estimated that 2.54% of the Georgia population suffers from CFS, which is 6 to 10 fold higher than previous population-based estimates in other geographic areas. These differences may reflect broader screening criteria and differences in the application of the case definition, however we cannot exclude the possibility that CFS prevalence may be higher in Georgia than other areas where it has been measured. Although the study did not identify differences in overall prevalence between metropolitan, urban, and rural Georgia populations, it did suggest the need for additional stratified analyses by geographic strata. [The complete article is available as a provisional PDF at http://www.pophealthmetrics.com/content/pdf/1478-7954-5-5.pdf . The fully formatted PDF and HTML versions are in production.] [Return to top] ------------------------------ Date: Sat, 9 Jun 2007 13:48:30 -0400 From: Fred Springfield <fredspringfield VERIZON.NET> Subject: RES: How common is chronic fatigue syndrome; how long is a piece of string? Editorial: How common is chronic fatigue syndrome; how long is a piece of string? Journal: Population Health Metrics 2007, 5:6 doi:10.1186/1478-7954-5-6 Author: Peter D White Affiliation: Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London, Queen Mary School of Medicine and Dentistry, London, UK, EC1A 7BE Email: <p.d.white qmul.ac.uk> Submission date 8 May 2007 Acceptance date 8 June 2007 Publication date 8 June 2007 Article URL http://www.pophealthmetrics.com/content/5/1/6 Commentary on Prevalence of chronic fatigue syndrome in metropolitan, urban, and rural Georgia William C Reeves, James F Jones, Elizabeth Maloney, Christine Heim, David C Hoaglin, Roumiana S Boneva, Marjorie Morrissey and Rebecca Devlin One of the most difficult tasks in medicine is to accurately measure how common illnesses are. Why do we do it? Justifications include being able to plan health care and public health priorities, as well as highlighting specific diseases for extra funding for both health care and research. Yet the jobbing physician at the sharp edge of clinical practice cares little about the exact prevalence of a disease or illness, since this is all too obvious from the frequency of the problems presented by patients who come through the door. How do you measure a syndrome? If the disease in question has no biological marker and is difficult to define clinically, the problem of working out the accurate prevalence becomes esoteric. Chronic fatigue syndrome (CFS) is just such an illness. It has as many synonyms as putative causes, being also called myalgic encephalomyelitis, chronic immune dysfunction syndrome, and post-viral fatigue syndrome, amongst others. Since fatigue is one of the most common symptoms reported by patients in general, delineating a specific syndrome with fatigue as a central feature risks arbitrary decisions about ascertainment. Do we categorise the syndrome on the basis of the severity of fatigue, the number of associated symptoms, or the severity of the resultant disability? Even measuring the consequent disability gives us problems since there are only weak correlations between subjective and objective observations . It is therefore no great surprise that half of all doctors do not even believe it exists . And yet, patients and their organisations constantly criticize doctors both for not believing in the existence of CFS and for not taking patients seriously. Even politicians seem to take the problem more seriously than some doctors do. This may be as much to do with successful lobbying as the economic costs of CFS, which have been estimated as $9 billion per annum just for lost productivity in the USA . Doctors don’t understand things they can’t see or measure, and patients mistrust doctors who don’t understand them. We are in a conundrum. One way forward The Centers for Disease Control and Prevention (CDC) in the United States of America are one of the few health care agencies who do take CFS seriously, to the extent of supporting a $4 million public education campaign, which started last year . They have also led the way in providing operationalised criteria in order to standardize the diagnosis of CFS . Their latest research programme has been based on a large survey of the adult (18-59 years old) population of the state of Georgia, USA, in order to better understand the epidemiology and etiology of CFS . Their previous study of prevalence, in Wichita, Kansas, suggested a prevalence of 0.24% . Another independent population survey in Chicago suggested a prevalence of 0.42% . The CDC has now repeated and extended the Wichita study in Georgia, and found a prevalence of between six and ten times greater, with 2.5% of the population suffering from CFS . If this prevalence was both accurate and representative of the USA as a whole, this would suggest that some 7.5 million Americans were sufferers, compared to the previous estimates of 0.7 to 1.2 million. A cautious interpretation Could this really be true? The authors are sensibly cautious in their interpretations, and point out the uncertainties inherent within the study. There are three main reasons why we should be cautious about interpretation and generalizing from this finding. Compared to previous studies, there were important differences in the method of ascertainment used in the Georgia study that may help to explain the greater prevalence. Most importantly, the Georgia study used a different initial screening question. Instead of asking whether a household member was suffering from “fatigue”, as previously done, the screening question asked about being “unwell”, by which was meant having one or more of the following symptoms for a month or more: “fatigue, cognitive impairment, unrefreshing sleep, muscle pain, joint pain, sore throat, tender lymph nodes, or headache” (all being likely symptoms of CFS). The authors suggested that this stratagem picked up an extra 11.5% of CFS cases. A strength of the Georgia survey was the use of standardised measures of symptoms and disability. However in order to count someone as fatigued - the central criterion for a diagnosis of CFS - individuals only needed to score the median or more of the well population, either for fatigue or inactivity. In a previous study, the same authors found that using such standardised measures picked up three times as many cases of CFS than verbatim enquiries . These methodological differences mean it is not possible to directly compare the prevalence of CFS in Georgia with previous studies. Comorbid psychiatric conditions may have inflated the prevalence. A previous study found an equally high point prevalence of CFS (2.6%), by surveying United Kingdom primary care patients . However, when those patients who also had a comorbid psychiatric disorder were excluded, the prevalence fell to 0.5%. Although it will be important to publish the prevalence of comorbid psychiatric disorders in the Georgian survey, the argument can still be put that these comorbid psychiatric disorders were secondary to having chronic ill-health, rather than the primary and explanatory condition. The current design cannot determine the direction of causality, although previous longitudinal studies suggest that psychiatric ill health can both follow and precede CFS [11, 12]. Georgia may not be representative of the USA as a whole. For instance, we do not know the body mass index (BMI) of the Georgian sample. The Wichita sample of CFS cases contained 43% of subjects with a BMI of 30 or over, representing significant obesity . This compares with 20% in the USA as a whole . Since obesity is associated with fatigue , a similar proportion in Georgia might inflate the prevalence of CFS. To conclude What can we conclude from this very large survey? Although methodological issues may help to explain the high prevalence of CFS found in this study, the argument can still be made that the prevalence of CFS is greater than previously thought [10, 15]. CFS is at least as common in ethnic minorities in the USA as in the ethnic Caucasian majority; a welcome replication of previous studies . CFS is not an exclusively white syndrome. Social issues may help to explain why women suffer CFS more than men. But perhaps the most important conclusion is that there were about twice as many people in Georgia who were unwell with fatigue, who did not meet the criteria for CFS. Our current criteria for diagnosing CFS are arbitrary , and we need to widen the net to capture all those people who become so chronically tired and unwell that they can’t live their lives to their full potential. The jobbing physician does not close the door on those who don’t meet criteria. Conflict of interest Professor White has collaborated with some of the authors in research into CFS. References 1. Afari N, Buchwald D: Chronic fatigue syndrome: a review. Am J Psychiatry 2003, 160:221-236. 2. Thomas MA, Smith AP: Primary healthcare provision and chronic fatigue syndrome: a survey of patients’ and General Practitioners’ beliefs. BMC Fam Pract 2005, 6:49. 3. Reynolds KJ, Vernon SD, Bouchery E, Reeves WC: The economic impact of chronic fatigue syndrome. Cost Effectiveness Resource Allocation 2004, 2:4. 4. Centers for Disease Control and Prevention: Chronic Fatigue Syndrome Awareness campaign. 2006 [http://www.cdc.gov/cfs/awareness.htm] 5. Reeves WC, Lloyd A, Vernon SD, Klimas N, Jason LA, Bleijenberg G, Evengard B, White PD, Nisenbaum R, Unger ER: Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution. BMC Health Services Research 2003, 3:25. 6. Reeves WC, Jones JF, Maloney E, Heim C, Hoaglin DC, Boneva1 RS, Morrissey M, Devlin R. Prevalence of chronic fatigue syndrome in metropolitan, urban, and rural Georgia. Population Metrics (this issue). 7. Reyes M, Nisenbaum R, Hoaglin DC, Unger ER, Emmons C, Randall B, Stewart JA, Abbey S, Jones JF, Gantz N, Minden S, Reeves WC: Prevalence and incidence of chronic fatigue syndrome in Wichita, Kansas. Arch Int Med 2003, 163:1530-1536. 8. Jason LA, Richman JA, Rademaker AW, Jordan KM, Plioplys AV, Taylor RR, McCready W, Huang CF, Plioplys S: A community-based study of chronic fatigue syndrome. Arch Int Med 1999, 159:2129-2137. 9. Reeves WC, Wagner D, Nisenbaum R, Jones JF, Gurbaxani B, Solomon L, Papanicolaou DA, Unger ER, Vernon SD, Heim C: Chronic fatigue syndrome A clinically empirical approach to its definition and study. BMC Medicine 2005, 3:19. 10. Wessely S, Chalder T, Hirsch S, Wallace P, Wright D: The prevalence and morbidity of chronic fatigue and chronic fatigue syndrome: a prospective primary care study. Am J Public Health 1997, 87:14491455. 11. Hickie I, Koschera A, Hadzi-Pavlovic D, Bennett B, Lloyd A: The temporal stability and co-morbidity of prolonged fatigue: A longitudinal study in primary care. Psychol Med 1999, 29:855861. 12. van der Linden G, Chalder T, Hickie I, Koschera A, Sham P, Wessely S: Fatigue and psychiatric disorder: different or the same? Psychol Med 1999, 29:863868. 13. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan SJ: The continuing epidemics of obesity and diabetes in the United States. JAMA 2001, 286:1195-1200. 14. Lim W, Hong S, Nelesen R, Dimsdale JE: The association of obesity, cytokine levels, and depressive symptoms with diverse measures of fatigue in healthy subjects. Arch Intern Med 2005, 165:910-915. 15. Evengård B, Jacks A, Pedersen NL, Sullivan PF: The epidemiology of chronic fatigue in the Swedish twin registry. Psychol Med 2005, 35:1327-1336. 16. Sullivan PF, Pedersen NL, Jacks A, Evengård B: Chronic fatigue in a population sample: definitions and heterogeneity. Psychol Med 2005, 35:1337-1348. [Return to top] ------------------------------ Date: Sun, 10 Jun 2007 12:43:47 -0700 From: "Jill McLaughlin <jillmclaughlin comcast.net>.........via Co-Cure Moderators" Subject: NOT, RES: Problems with the New CDC CFS Prevalence Estimate - Leonard Jason, Ph.D., DePaul University The following has been posted to the IACFS/ME website. Jill McLaughlin _____________________________________ At the last IACFS/ME Board meeting in Salt Lake City, we were informed that an article would soon be published concerning the CDC's new prevalence estimates indicating six to ten times more individuals in the US had CFS. On scientific grounds, I had several concerns with these estimates, and after I brought up my concerns, the Board asked if I might post my reactions on the IACFS/ME website.
I agreed to do this, and my opinions are below and do not represent the views of the IACFS/ME. Leonard Jason, Ph.D., DePaul University http://www.pophealthmetrics.com/content/5/1/5 Problems with the New CDC CFS Prevalence Estimates Leonard Jason, Ph.D., DePaul University By the early to mid 1990s, the general consensus was that CFS was a relatively rare disorder affecting primarily white, middle-class women. Prevalence estimates of this illness from the CDC ranged from .002% to .0073% (Gunn et al., 1993) suggesting that there were less than 20,000 individuals in the U.S. with this illness. Toward the late 1990s, Jason, Richman and colleagues (1999) used more rigorous community-based samples and found that approximately .42% of the sample was determined to have CFS, or approximately 800,000 people from the US (Jason, Richman et al., 1999). These overall prevalence estimates were later corroborated by the CDC in another community-based sample (Reyes et al., 2003 estimated the CFS prevalence to be .24%). In Great Britain, community estimates of CFS rates were estimated to be 2.6% (or 2.6 cases among every 100 people; Wessely et al., 1997). One needs to examine a broadened CFS case definition to understand these CFS rates in Great Britain, and if these rates were applied to the US, there would be about 4 million people in the US with CFS. Wessely et al. (1997) indicated that of the 2.6% with CFS, psychological disorders were absent in only .5%. Individuals diagnosed with CFS in this epidemiologic study were subsequently compared to a sample of people with CFS who had been diagnosed from a hospital unit (Euba, Chalder, Deale & Wessely, 1995). Of the community sample, 59% felt their illness might be due to psychological or psychosocial causes compared to 7% for the hospital sample. In Wessely et al.'s (1996) community based sample, only 64% had sleep disturbances and 63% had postexertional malaise. These percentages are rather low, as both symptoms are critical features of CFS. These findings might provide a clue as to why Wessely and colleagues found CFS prevalence rates that were appreciably higher than those found by a second generation of CFS epidemiologic studies in the United States (Jason et al., 1999; Reyes et al., 2003). It is of interest that the Great Britain CFS rates are within the range of several mood disorders. Mood disorders are the most prevalent psychiatric disorders after anxiety disorders: for major depressive episode, the one-month prevalence is 2.2%, and lifetime prevalence is 5.8% (Regier et al., 1988). Major Depressive Disorder is an example of a primary psychiatric disorder, which has some overlapping symptoms with CFS. Fatigue, sleep disturbances and poor concentration occur in both depression and CFS. Some patients with Major Depressive Disorder also have chronic fatigue and other symptoms that can occur with depression (e.g., unrefreshing sleep, joint pain, muscle pain, impairment in concentration). Fatigue and these four symptoms also are defining criteria for CFS, based on the Fukuda et al. (1994) criteria. It is possible that some patients with a primary affective disorder could be misdiagnosed as having CFS. While fatigue is the principal feature of CFS, fatigue does not assume equal prominence in depression (Friedberg & Jason, 1998; Komaroff et al., 1996). Several CFS symptoms, including prolonged fatigue after physical exertion, night sweats, sore throats, and swollen lymph nodes, are not commonly found in depression. Moreover, illness onset with CFS is often sudden, occurring over a few hours or days, whereas primary depression generally shows a more gradual onset. Some individuals with CFS might have had psychiatric problems before and/or after CFS onset and yet, other individuals may only have primary psychiatric disorders with prominent somatic features. Including the latter type of patients in the current CFS case definition could confound the interpretation of epidemiologic and treatment studies. The CDC has recently released findings from a community-based epidemiologic study that occurred in Georgia (Reeves, Jones, Maloney, Heim, Hoaglin, Boneva, Morrissey, & Devlin, 2007). While the prior CFS prevalence rate was estimated to be .24% in Wichita, Kansas (Reyes et al., 2003), their new estimated prevalence rates were reported to be considerably higher with 2.54% (remarkably similar to the 2.6% rate in Great Britain, Wessely et al., 1997). The CDC now estimates that six to ten times more people have this illness than their previous reports in the US. In this study, the authors screened for persons who reported fatigue, problems with memory/concentration, unrefreshing sleep or pain rather than simply focusing on the single symptom of fatigue, and the authors indicated that these criteria increased the identified cases by 13%. In addition, the authors used what they referred to as standardized criteria to identify cases, and below we evaluate this new empirical CDC case def inition of CFS. To meet the new CFS criteria, individuals need to meet criteria on symptoms, level of disability and degree of fatigue, and each of these areas is described below. As one part of the standardized CDC criteria, the Symptom Inventory is used to operationalize the symptoms of CFS (Wagner et al., 2005). For each of 8 critical Fukuda et al. definitional symptoms, patients are asked to rate the symptom on perceived frequency (1 = a little of the time; 2 = some of the time; 3 = most of the time; 4 = all of the time) and severity or intensity of symptoms (the ratings were transformed to the following scale: 1 = mild, 2.5 = moderate, 4 = severe). The frequency and severity scores were multiplied, and the sums for the 8 critical Fukuda et al. (1994) symptoms were summed. Even with summed scores for the empirical case definition needing to be greater or equal to 25 (Reeves et al., 2005), the overall level of symptoms seems relatively low for patients with classic CFS symptoms (the criterion would be met if an individual rated only 2 symptoms as occurring all the time, and one was of moderate and the other of severe severity). In addition, the 8 case definition symptoms were based on a time period comprising the last month compared to what is specified in the Fukuda et al. (1994) criteria, which states that: "There needs to be the concurrent occurrence of 4 or more of the following symptoms, and all must be persistent or recurrent during 6 or more months of the illness and not predate the fatigue." This change in the case definition has the potential of including more individuals. Also, part of this new CDC empirical CFS criteria is the use of the Medical Outcomes Survey Short Form-36 (SF-36) to assess substantial reductions in occupational, educational, social or recreational activities. Using the SF-36, these criteria were defined as scores lower that the 25th percentile on the physical function, role physical function, social function, or role emotional. Because the individual only needs to meet one of these areas to meet the CFS criteria, the individual might not have any reductions in key areas of physical functioning, and only impairment in role emotional areas (e.g., problems with work or other daily activities as a result of emotional problems), and then the person could meet disability criteria for CFS. Ware, Snow, and Kosinsi (2000) found that mean for role emotional for a clinical depression group was 38.9, indicating that almost all those with clinical depression would meet criteria for being within the lower 25th percentile on this scale (which was a score of less than or equal to 66.7). In Peter White's Dec. 3. 2006 review (http://www.biomedcentral.com/imedia/1083914155124266_comment.pdf) of Reeves et al.'s (2007) article, he states: The use of physical function, role physical and social function sub-scales is consistent with the International Study criteria for CFS, which states that the illness "results in substantial reduction in previous levels of occupational, educational, social, or personal activities." (Reeves et al, 2003). The use of role emotional is not, since it specifically asks about change in function "as a result of any emotional problems". And later White states that "In order to make these important criteria consistent with other studies, I think the authors need to re-analyse their data, omitting this sub-scale." The last instrument used with the new CDC empirical CFS criteria is the Multidimensional Fatigue Inventory (MFI) (Smets, Garssen, Bonke, & DeHaes, 1995). Severe fatigue was defined as greater than or equal to 13 on the MFI general fatigue or greater than or equal to 10 on the reduced activity. In Peter White's Dec. 3, 2006 review of the Reeves et al.'s (2007) article (http://www.biomedcentral.com/imedia/1083914155124266_comment.pdf), he wrote: "This means that it would be possible to meet the fatigue criterion without significant fatigue; i.e. with reduced activity alone. This is inconsistent with the international study criteria for CFS." In support of this criticism by White, I believe that the general activity items refer to issues that a person with depression might easily endorse. If a person indicated that the following two items were entirely true: "I get little done", "I think I do very little in a day"; they would meet the fatigue criterion for the new CDC empirical cas e definition. Our group is currently studying individuals with major depressive disorder versus those with CFS, and we are finding individuals with a purely affective disorder being classified as having CFS with this new empirical case definition (Najar, Porter, & Jason, 2007). It is important to better understand the two CDC community based studies (Reyes et al., 2003; Reeves et al., 2007), and this is particularly important as their CFS estimated prevalence rates have changed so dramatically. Of the individuals who were identified as having CFS during the first study (Reyes et al., 2003) that occurred over a three year period (1997 through 2000), 58 were brought back for a two day inpatient study that occurred from December 2002 to July 2003, and only 16 (28% of the original group diagnosed with CFS) had a current consistent diagnosis of CFS, using traditional methods of making this diagnosis. When these investigators employed an empirically derived system (that was used in deriving the higher prevalence rates of 2.54% in the Georgia community based study), 43 rather than 16 individuals who had been traditionally diagnosed as having CFS met this new system. Clearly, this newly developed empirical system brings in many additional people to a CFS diagnosis. It is very possible that this new empirical classification does identify a group of individuals with high levels of fatigue, impairment, and symptoms, but it might also be identifying a group with high chronic distress and illness, rather than CFS as a unique disorder. It is at least possible that the 2.54% to 2.6% CFS rates both the United States and Great Britain are due to a broadening of the case definition and possible inclusion of cases with primary psychiatric conditions. Some CFS investigators would not see this as a confounding problem because they believe that high rates of psychiatric comorbidity indicate that CFS is mainly a psychiatric disorder (Abbey, 1993). CFS and depression are two distinct disorders, however, even if they share a number of common symptoms. Most importantly, the erroneous inclusion of people with primary psychiatric conditions in CFS samples will have detrimental consequences for the interpretation of both epidemiologic and treatment efficacy findings. Reeves et al. (2005) claims that the empirical definition identifies people with CFS in a more precise manner than can occur in the more traditional way. It is primarily the use of this new empirical case definition that has lead to the increase in CFS prevalence rates in the United States. In their use of the empirical case definition, several changes occurred to what had been previously recommended by an international expert committee (Reeves et al., 2003) of recommendations for the case definition of Fukuda et al. (1994). First, rather than excluding those with depressive disorder with melancholic features, only those with a current condition were excluded as opposed to what had been recommended. Of interest, of those 16 within the Reyes et al. (2003) study who had been classified with CFS using the more traditional methods, 6 had a past history of major depressive disorder with melancholic features (Reeves et al., 2005); and it is unclear how many of those 43 who were diagnosed using the empiric case definition had past depressive disorder with melancholic features. These individuals should have been excluded, and by including them, the broadening of the case definition has the potential to bring into the CFS category those with a primary psychiatric condition. More importantly, there was little agreement between the empirical method of classifying individuals with the more traditional method of comparing whether an individual met the case definition on their critical symptoms. Rather than assuming that this might be a problem with the CFS empirical case definition, they concluded that the more traditional way of diagnosing patients was flawed. As an example of this problem, one individual who was classified as being in remission for CFS using the traditional method was diagnosed with current CFS using the CDC's empirical approach. Papers are now appearing in the literature using this empirical case definition of CFS, and many have received considerable media attention. For example, Heim et al. (2006) recently used this new empiric case definition and the Wichita study to explore the influence of early adverse experience on risk for developing CFS. The authors concluded that childhood trauma is an important risk factor for CFS. In fact, among those with CFS, 62.8% had some type of early abuse. This is in contrast to findings reported by Taylor and Jason (2002) who found prevalence rates of sexual and physical abuse history among individuals with CFS were comparable with those found in individuals with other conditions involving chronic fatigue, including medically based conditions. Relative to those with CFS who report such history, most individuals with CFS did not report histories of interpersonal abuse. The Reeves et al. (2005) article clearly used instruments (such as the SF-36) to make diagnostic decisions, rather than encompassing more specific criteria involving aspects of the illness (for example, whether with rest, all symptoms disappear). Given the high variability in symptom severity among persons with fatigue, standardized procedures should be employed for determining whether or not a particular symptom is severe enough to qualify as one of the symptoms required for the diagnosis of fatigue. But one needs to be extremely careful about deciding whether standardized instruments and scores need to include contextual issues, and often they do not. For example, if a patient endorses a symptom such as post-exertional malaise, standardized questions should include duration, frequency, and severity of the symptom including onset, pattern, intensity, and associated factors (see Hawk et al. 2007). Clinical judgment, which has been used in most past studies to diagnoses CFS, remain s an important role even for diseases like lupus, which use a combination of clinical judgment, patient report, and objective measures to come up with a diagnosis. This currently is not occurring with the CFS empirical case definition developed by the CDC. Some researchers have posited that FMS, CFS, and IBS can be considered functional somatic syndromes (Barsky & Borus, 1999). Functional somatic syndromes are characterized by diffuse, poorly-defined symptoms that cause significant subjective distress and disability, cannot be corroborated by consistent documentation of organic pathology, and are highly prevalent even in healthy, non-patient groups (Barsky & Borus, 1999). Accurate measurement and classification of CFS, FMS and IBS is imperative when evaluating the diagnostic validity of controversial disease entities alternatively labeled, 'functional somatic syndromes'. For example, results of a study by Taylor, Jason and Schoeny (2001) provided support for distinctions between the five conditions of FMS, CFS, somatic depression, somatic anxiety, and IBS, but this will only occur when using symptom criteria that matches actual diagnostic criteria for these illnesses. Measurement that fails to capture the unique characteristics of th ese illnesses might inaccurately conclude that only distress and unwellness characterize these illnesses, thus inappropriately supporting a unitary hypothetical construct called functional somatic syndromes. Ultimately, using a broad or narrow definition of CFS will have important influences on CFS epidemiologic findings, on rates of psychiatric comorbidity, and ultimately on the likelihood of finding biological markers. References Abbey, S.E. (1993). Somatization, illness attribution and the sociocultural psychiatry of chronic fatigue syndrome. In B.R. Bock & J. Whelan (Eds.), Chronic Fatigue Syndrome. (pp. 238-261). New York: John Wiley & Sons. Barsky AJ, & Borus JF (1999) Functional somatic syndromes. Annals of Internal Medicine, 130, 910-921. Euba, R., Chalder, T., Deale, A., & Wessely, S. (1996). A comparison of the characteristics of Chronic Fatigue Syndrome in primary and tertiary care. 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Early adverse experience and risk for chronic fatigue syndrome: Results from a population-based study. The Archives of General Psychiatry, 63, 1258-1266. Jason, L.A., Richman, J.A., Rademaker, A.W., Jordan, K.M., Plioplys, A.V., Taylor, R., et al. (1999). A community-based study of chronic fatigue syndrome. Archives of Internal Medicine. 159, 2129-2137. Komaroff, A.L., Fagioli, L.R., Geiger, A.M., Doolittle, T.H., Lee, J., Kornish, R.J., Gleit, M.A., Guerriero, R.T. (1996). An examination of the working case definition of Chronic Fatigue Syndrome. The American Journal of Medicine, 100, 56-64. Najar, N., Porter, N., & Jason, L.A. (2007, Jan.). Evaluating the CDC new case definition. Poster presented at the International Association of Chronic Fatigue Syndrome, Ft. Lauderdale, Fl. Reeves, W.C., Lloyd, A., Vernon, S.D., Klimas, N., Jason, L., Bleijenberg, G., Evengard, B., White, P.D., Nisenbaum, R., Unger, E.R.(2003). 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Copyright IACFS, 2007 All Rights Reserved [Return to top] ------------------------------ Date: Mon, 11 Jun 2007 12:22:35 -0400 From: Co-Cure Moderator <ray@CO-CURE.ORG> Subject: RES: Gabapentin (U.S. Brand Name: Neurontin) Shown Effective for Fibromyalgia Pain U.S. Department of Health and Human Services NATIONAL INSTITUTES OF HEALTH NIH News National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) <http://www.niams.nih.gov/> FOR IMMEDIATE RELEASE: Monday, June 11, 2007 CONTACT: Ray Fleming, 301-496-8190, <e-mail: firstname.lastname@example.org> GABAPENTIN SHOWN EFFECTIVE FOR FIBROMYALGIA PAIN New research supported by the National Institutes of Health's National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) shows that the anticonvulsant medication gabapentin, which is used for certain types of seizures, can be an effective treatment for the pain and other symptoms associated with the common, often hard-to-treat chronic pain disorder, fibromyalgia. In the NIAMS-sponsored, randomized, double-blind clinical trial of 150 women (90 percent) and men with the condition, Lesley M. Arnold, M.D., director of the Women's Health Research Program at the University of Cincinnati College of Medicine, and her colleagues found that those taking gabapentin at dosages of 1,200 to 2,400 mg daily for 12 weeks displayed significantly less pain than those taking placebo. Patients taking gabapentin also reported significantly better sleep and less fatigue. For the majority of participants, the drug was well tolerated. The most common side effects included dizziness and sedation, which were mild to moderate in severity in most cases. NIAMS Director Stephen I. Katz. M.D., Ph.D., remarked that "While gabapentin does not have Food and Drug Administration approval for fibromyalgia, I believe this study offers additional insight to physicians considering the drug for their fibromyalgia patients. Fibromyalgia is a debilitating condition for which current treatments are only modestly effective, so a study such as this is potentially good news for people with this common, painful condition." Fibromyalgia is a chronic disorder characterized by chronic, widespread muscle pain and tenderness, and is frequently accompanied by fatigue, insomnia, depression, and anxiety. It affects three million to six million Americans, mostly women, and can be disabling. The precise cause of fibromyalgia in not known, but research suggests it is related to a problem with the central nervous system's processing of pain. As with some other chronic pain conditions, people with fibromyalgia often develop a heightened response to stimuli, experiencing pain that would not cause problems in other people. Yet, unlike many other pain syndromes, there is no physical evidence of inflammation or central nervous system damage. Although gabapentin has little, if any, effect on acute pain, it has shown a robust effect on pain caused by a heightened response to stimuli related to inflammation or nerve injury in animal models of chronic pain syndromes. Researchers have suspected that it might have the same effect in people with fibromyalgia. The new research, published in the April 2007 edition of "Arthritis & Rheumatism", indicates the suspicions were correct. Although the researchers cannot say with certainty how gabapentin helps reduce pain, Dr. Arnold says one possible explanation involves the binding of gabapentin to a specific subunit of voltage-gated calcium channels on neurons. "This binding reduces calcium flow into the nerve cell, which reduces the release of some signaling molecules involved in pain processing," she says. How gabapentin improves sleep and other symptoms is less clear, and there are probably different mechanisms involved in fibromyalgia symptoms. "Gabapentin improved sleep, which is an added benefit to patients with fibromyalgia who often report unrefreshing or disrupted sleep," Dr. Arnold says. What is important is that people with fibromyalgia now have a potential new treatment option for a condition with few effective treatments. "Studies like this give clinicians evidence-based information to guide their treatment of patients," says Dr. Arnold. The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the Department of Health and Human Services' National Institutes of Health, is to support research into the causes, treatment and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases. For more information about NIAMS, call the information clearinghouse at (301) 495-4484 or (877) 22-NIAMS (free call) or visit the NIAMS website at <http://www.niams.nih.gov>. The National Institutes of Health (NIH) -- The Nation's Medical Research Agency -- includes 27 Institutes and Centers and is a component of the U. S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical, and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit <http://www.nih.gov>. ---------------------------- Arnold, LM et al. Gabapentin in the treatment of fibromyalgia; a randomized, double-blind, placebo-controlled multicenter trial. "Arthritis Rheum". 2007; 56: 1336-1344. ---------------------------- ## [Return to top] ------------------------------ Date: Mon, 11 Jun 2007 12:49:09 -0400 From: "Bernice A. Melsky" <bernicemelsky VERIZON.NET> Subject: RES: Fibromyalgia syndrome Fibromyalgia syndrome. J Rheumatol. 2007 Jun;34(6):1415-25. Mease P, Arnold LM, Bennett R, Boonen A, Buskila D, Carville S, Chappell A, Choy E, Clauw D, Dadabhoy D, Gendreau M, Goldenberg D, Littlejohn G, Martin S, Perera P, Russell IJ, Simon L, Spaeth M, Williams D, Crofford L. Division of Rheumatology Research, Swedish Medical Center, Clinical Professor of Medicine, University of Washington, Seattle, WA, USA. PMID: 17552068 The fibromyalgia syndrome (FM) workshop at OMERACT 8 [Note: OMERACT = "Outcome Measures in Rheumatoid Arthritis Clinical Trials"] continued the work initiated in the first FM workshop at OMERACT 7 in 2004. The principal objectives were to work toward consensus on core domains for assessment in FM studies, evaluate the performance quality of outcome measures used in a review of recent trials in FM, and discuss the research agenda of the FM working group. An initiative to include the patient perspective on identification and prioritization of domains, consisting of focus groups and a patient Delphi exercise, was completed prior to OMERACT 8. Patient-identified domains were, for the most part, similar to those identified by clinician-investigators in terms of symptoms and relative importance. However, patients identified certain domains, such as stiffness, that were not included by physicians, and emphasized the importance of domains such as dyscognition and impaired motivation. Many of the principal domains agreed upon by the clinician-investigators, patients, and OMERACT participants, including pain, fatigue, sleep, mood, and global measures, have been used in clinical trials and performed well when viewed through the OMERACT filter. The research agenda items reviewed and approved for continued study included development of objective "biomarkers" in FM, development of a responder index for FM, and coordination with the WHO's International Classification of Functioning Disability and Health (ICF) Research Branch and the US National Institutes of Health's Patient Reported Outcome Measures Information System network (PROMIS) to develop improved measures of function, quality of life, and participation. The OMERACT process has provided a framework for identification of key domains to be assessed and a path toward validation and standardization of outcome measures for clinical trials in FM. [Return to top] ------------------------------ Date: Mon, 11 Jun 2007 11:09:24 -0700 From: Kimberly Hare <kimberly_ohare YAHOO.COM> Subject: RES: Multiple chemical sensitivity and workplace discrimination: The national EEOC ADA research project [This may be of interest given the fact that a subset of people with ME/CFS also have MCS.] Multiple chemical sensitivity and workplace discrimination: The national EEOC ADA research project. Work. 2007;28(4):391-402.Click here to read Links Vierstra CV, Rumrill PD, Koch LC, McMahon BT. Kent State University, Department of Educational Foundations & Special Services, Kent, OH, USA. PMID: 17522460 Information from the Integrated Mission System of the United States Equal Employment Opportunity Commission (EEOC) was used to investigate the employment discrimination experiences of Americans with multiple chemical sensitivity (MCS) in comparison to Americans in a general disability group with allergies, asthma, HIV, gastrointestinal impairment, cumulative trauma disorder and tuberculosis. Specifically, the researchers examined demographic characteristics of the charging parties; the industry designation, location, and size of employers against whom allegations were filed; the nature of discrimination (i.e., type of adverse action) alleged to occur; and the legal outcomes or resolutions of these allegations. Findings indicate that persons with MCS were, on average, older than the comparison group and comparatively overrepresented by Caucasians and women. People with MCS were proportionally more likely than the comparison group to allege discrimination related to reasonable accommodations. People with MCS were proportionally more likely than the comparison group to file allegations against employers in the manufacturing and public administration industries, employers with 201-500 workers, and employers in the Western Census region. People with MCS were proportionally more likely than the comparison group to receive non-merit resolutions as a result of the EEOC's Americans with Disabilities Act Title I investigatory process. Implications for policy and advocacy are addressed. [Return to top] ------------------------------
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