Chronic Fatigue Syndrome and Primary Fibromyalgia Syndrome as recognized by GPs.

BACKGROUND: Prevalence studies on Chronic Fatigue Syndrome (CFS) are rare. Because of the similarity in symptoms, the prevalence of Primary Fibromyalgia Syndrome (PFS) was investigated at the same time. OBJECTIVES: To determine the prevalence of CFS and PFS as recognized by GPs in The Netherlands and to inform them of the existence of CFS. METHODS: A postal questionnaire was sent to all GPs. RESULTS: The questionnaire was returned by 60% of the GPs. Seventy-three per cent reported one or more CFS patients and 83% one or more PFS patients in their practice. CONCLUSION: The estimated prevalence of CFS as recognized by GPs of 112 (PFS 157) patients per 100,000 is a minimum estimate.

The persistence of fatigue in chronic fatigue syndrome and multiple sclerosis: development of a model.

The cause of chronic fatigue syndrome (CFS) is unknown. With respect to factors perpetuating fatigue, on the other hand, a model has been postulated in the literature in which behavioral, cognitive, and affective factors play a role in perpetuating fatigue. In the present study, this hypothesized model was tested on patients with CFS and on fatigued patients with multiple sclerosis (MS). The model was formulated in terms of cause-and-effect relationships and an integral test of this model was performed by the statistical technique, "structural equation modeling," in 51 patients with chronic fatigue syndrome and 50 patients with multiple sclerosis matched for age, gender, and education. Attributing complaints to a somatic cause produced low levels of physical activity, which in turn had a causal effect on fatigue severity. Depression had to be deleted from the model. Sense of control over symptoms and focusing on bodily symptoms each had a direct causal effect on fatigue. The model showed an excellent fit for CFS patients, but was rejected for MS patients. Therefore, a new model for MS patients had to be developed in which sense of control had a causal effect on fatigue. In the MS model, no causal relationship was found between the physical state as measured by the Expanded Disability Status Score (EDSS) and fatigue or functional impairment. The present study shows that cognitive and behavioral factors are involved in the persistence of fatigue. Treatment should be directed at these factors. The processes involved in the subjective experience of fatigue in CFS were different from the processes related to fatigue in MS.

Yersinia enterocolitica and the chronic fatigue syndrome.

OBJECTIVES: To investigate the potential role of Yersinia enterocolitica in patients with chronic fatigue syndrome (CFS). METHODS: An immunoblot technique was used to detect antibodies to various Yersinia outer membrane proteins (YOPs) in serum samples from 88 patients with CFS and 77 healthy neighbourhood controls, matched for gender and age. RESULTS: The prevalence of IgG and IgA antibodies to various Yersinia outer membrane proteins (YOPs) did not differ between patients with CFS and healthy controls. Twenty-four patients (27%) and nineteen controls (25%) had IgG antibodies to one or more YOPs. Four patients and two controls had both serum IgG and IgA antibodies to at least two different YOPs, compatible with a recent or persistent infection. Although all patients with positive IgG and IgA reactions to two or more YOPs had symptoms that could point to persistent Yersinia infection, these symptoms were also found frequently in patients without antibodies to YOPs. CONCLUSIONS: We conclude that Y. enterocolitica is unlikely to play a major role in the aetiology of CFS.

Evaluating neuropsychological impairment in chronic fatigue syndrome.

This study was designed to provide an estimate of the prevalence of neuropsychological impairment in chronic fatigue syndrome (CFS), to evaluate the concordance between impairment found on standardized tests and self-reported neuropsychological problems, and to study the relationship between neuropsychological functioning and fatigue severity and psychological processes. We adopted an individual approach to determine neuropsychological impairment as contrasted with the group-comparisons approach used in previous studies. Also, correction for premorbid functioning and confounders was done on an individual basis. The results show that a minority of participants were impaired in neuropsychological functioning. There was no relationship between neuropsychological impairment on standardized tests and self-reported memory and concentration problems. Neuropsychological functioning was not related to fatigue or depression. Slowed speed of information processing and motor speed were related to low levels of physical activity.

[Improved prognosis of functional abdominal complaints by attending to psychic factors]. / Betere prognose van functionele buikklachten door aandacht voor psychische factoren.

OBJECTIVE: To determine the assessment by physicians of psychic factors in patients with functional abdominal complaints, and the relationship between the assessment and the evolution of the abdominal complaints. DESIGN: Prospective, descriptive. SETTING: Outpatient Clinic Internal Medicine, University Hospital Nijmegen, the Netherlands. METHODS: 120 patients with functional abdominal complaints were asked to indicate by questionnaires the severity and meaning of their complaints prior to and at the end of the visits to their internist. Internists were asked how they rated the somatic and non-somatic complaint dimensions in their patients. RESULTS: Overall, internists perceived the severity and details of the abdominal complaints correctly. Prognostically unfavourable complaint-related cognitions and emotions were perceived less correctly. During the outpatient consulting period, patients' anxiety and somatic attributions diminished, especially when the internist had perceived these aspects correctly. Six months after the first outpatient visit the abdominal complaints of these reassured patients had improved, compared with patients with persistent somatic attributions; the latter made more frequent use of health care services at follow-up (GP visits, drug use). CONCLUSION: Systematic exploration of somatic and non-somatic complaint dimensions by physicians could be an important tool in improving the prognosis and diminishing the medical consumption in patients with functional abdominal complaints.

[Rational use of antibiotics by the dentist can prevent microbial resistance]. / Rationeel antibioticagebruik door tandarts kan resistentie voorkomen.

Worldwide resistance of microorganisms to antibiotics is becoming a problem of major concern. An antibiotic policy which tries to control the development of resistance by rational use is needed in all fields where antibiotics are prescribed. In dental practice, apart from endocarditisprophylaxis, prophylaxis is leukopenic patients and prophylaxis after dental implants, antibiotics can be used to support local therapy of an dentoalveolar abscess or refractory periodontitis. In the majority of these cases, a small spectrum penicillin is therapy of choice.

Persisting improvement in complaint-related cognitions initiated during medical consultations in functional abdominal complaints.

BACKGROUND: Previously it was shown that during a series of out-patient consultations dysfunctional complaint-related cognitions and anxiety diminished significantly in patients with functional abdominal complaints (IBS). The aim of the present study was to assess the maintenance of positive changes initiated during medical consultations in the patients' complaint-related cognitions and anxiety, as well as the influence of these cognitions on the severity of the complaints, 6 months after the first visit to the out-patient clinic. METHODS: One hundred and five consecutive patients with IBS referred by their general practitioners to the out-patient clinic for internal medicine completed questionnaires about their complaints and their complaint-related cognitions and anxiety before the first and after the last out-patient visit and again at follow-up, 6 months after the first out-patient consultation. RESULTS: Positive changes in the patients' complaint-related cognitions during the consulting period were found to persist during the follow-up period. Improvement in abdominal complaints at follow-up was found to be related to the level of the patients' state anxiety, fear of cancer, and catastrophizing cognitions at the last out-patient visit. CONCLUSIONS: Medical consultations can bring about long-lasting positive changes in prognostically unfavourable cognitions and anxiety. These changes appear to be related to a better outcome of IBS.

[Attacks of abdominal pain in a young Turkish woman with C1 esterase inhibitor deficiency]. / Aanvalsgewijze buikpijn bij een jonge Turkse vrouw met een C1-esteraseremmerdeficiëntie.

A 19-years-old Turkish woman had recurrent attacks of abdominal pain. She underwent numerous diagnostic procedures and an appendectomy. In addition, imminent pethidine addiction developed. It was only after the patient presented with a swollen painless wrist, some years later, that the correct diagnosis was made: C1 esterase inhibitor deficiency. Early recognition may prevent a prolonged course and is mandatory as the disease is potentially life-threatening.

Physical activity in chronic fatigue syndrome: assessment and its role in fatigue.

This paper describes the assessment of physical activity in chronic fatigue syndrome (CFS) and investigated the following questions: Do patients with CFS have low levels of physical activity; is there a relationship between actual level of physical activity and fatigue; can self-report measures adequately assess actual level of physical activity; what is the role of cognitions with respect to physical activity; and are results with respect to physical activity specific to CFS? Three different types of activity measures were used: self-report questionnaires, a 12-day self-observation list, and a motion-sensing device (Actometer) which was used as a reference for actual activity level. Fifty-one patients with CFS, 50 fatigued patients with multiple sclerosis (MS), and 53 healthy subjects participated in this study. Although none of the self-report questionnaires showed high correlations with the Actometer, questionnaires that require simple ratings of specified activities were related to the Actometer and can be used as acceptable substitutes, in contrast to instruments that require general subjective interpretations of activity that had low or non-significant correlations with the Actometer. Actometer results showed that CFS patients and MS patients had similar activity levels and both groups were significantly less active than healthy subjects. Compared to MS patients, CFS patients were more likely to indicate that they had been less active than other persons they knew. Activities which patients expected to result in higher fatigue levels were less frequently performed. Patients with CFS had significantly higher scores on this measure than MS patients and healthy subjects. Low levels of physical activity were related to severe fatigue in CFS but not in MS. In conclusion, although CFS patients have similar low activity levels than MS patients, there are also important differences between both groups: in CFS cognitive factors are more prominently involved in producing the low activity levels than in MS and in CFS patients activity level is related to fatigue but not in MS.

Do patients with irritable bowel syndrome in primary care really differ from outpatients with irritable bowel syndrome?

BACKGROUND: Little is known about the comparability of outpatients with irritable bowel syndrome (IBS) and patients with IBS in primary care with regard to severity of complaints, perceived limitations, other aspects of the complaints, and sex differences. AIMS: To compare outpatients with IBS with primary care patients with IBS. PATIENTS: One hundred and nine patients with IBS were recruited from general practices in Amsterdam and 86 patients with IBS were recruited from the outpatient clinic of the Department of Internal Medicine of the University Hospital in Nijmegen. METHODS: Each patient completed a questionnaire on demographic variables, abdominal complaints, related complaints, and attributed causes of their abdominal complaints. The scores of the two groups were compared by univariate and multivariate analysis. RESULTS: The outpatient group contained significantly more men, reported more severe abdominal pain, more frequent complaints, more interference with daily activities, and a higher degree of avoidance of activities (p < 0.01) than the primary care group. When each sex was analysed separately, these differences remained for female (p < 0.01) but not for male patients. Outpatients were more likely to attribute their complaints to somatic causes (p < 0.01), whereas primary care patients were more likely to attribute their complaints to stress (p < 0.01) or their agitated way of life (p < 0.05). Multivariate analysis showed that a high severity score, a large number of additional complaints, and a low score on the stress attribution were important determinants for being in the outpatient group. CONCLUSIONS: Female outpatients consider their complaints to be more serious and interfering than do patients with IBS in primary care. Male outpatients were comparable to primary care patients with IBS. More research needs to be done into sex specific differences in IBS and into the factors that influence the decision to refer a patient with IBS.

Cognitive-behavioral group therapy for irritable bowel syndrome: effects and long-term follow-up.

Little is known about the effectiveness of cognitive behavioral treatment for patients with irritable bowel syndrome on a group basis. Previous studies have used only small samples, and studies with long term follow-up are lacking. The arm of the present study was to investigate: a) the effectiveness of a cognitive-behavioral group treatment compared with a waiting list control condition in alleviating abdominal complaints and b) the long term effectiveness of cognitive-behavioral group treatment. In study 1, we performed a controlled study with 25 patients in the group treatment condition and 20 patients in the waiting list control condition. Treatment consisted of eight 2-hour group sessions over a period of 3 months. In study 2, all patients were treated and followed up for an average of 2.25 years (range 6 months-4 years) after the completion of the group treatment. The abdominal complaints of the patients who underwent treatment were found to improve significantly more than the complaints of the patients awaiting treatment. Moreover, in agreement with the purpose of the therapy, the number of successful coping strategies was found to increase more and patients' avoidance behavior was found to decrease more in the treatment group than in the waiting list control group. The positive changes appeared to persist during follow-up. Cognitive-behavioral group treatment is effective in alleviating irritable bowel syndrome, in stimulating coping strategies, and in reducing avoidance behavior. At long term follow-up, the abdominal complaints, the number of successful coping strategies, and the avoidance behavior were still improved compared with the pretreatment assessment.

The measurement of fatigue in patients with multiple sclerosis. A multidimensional comparison with patients with chronic fatigue syndrome and healthy subjects.

OBJECTIVE: To provide a multidimensional characterization of fatigue in patients with multiple sclerosis (MS). DESIGN: Cross-sectional design. Fifty patients with clinically definite MS were compared on the dimensions of fatigue with 51 patients with chronic fatigue syndrome (CFS) and 53 healthy subjects. RESULTS: Fourty-six percent of the patients with MS reported fatigue to be present at least once a week. Patients with MS and patients with CFS had significantly higher subjective fatigue severity scores than healthy subjects. Patients with MS and patients with CFS had significantly higher scores on measures of psychological well-being than healthy subjects. Patients with MS had scores similar to those of patients with CFS, except that patients with CFS had significantly higher somatization scores. High somatization scores reflect strong focusing on bodily sensations. Both groups of patients were significantly less active than the healthy subjects. The Kurtzke Expanded Disability Status Scale (EDSS) and the Beck Depression Inventory scores were not related to subjective fatigue severity. In patients with MS and in patients with CFS, subjective fatigue severity was related to impairment in daily life, low sense of control over symptoms, and strong focusing on bodily sensations. In CFS, but not in MS, evidence was found for a relationship between low levels of physical activity and attributing symptoms to a physical cause and between subjective fatigue severity and physical activity. CONCLUSIONS: Patients with MS experienced significant fatigue, which had a significant impact on daily functioning and was not related to depression on Expanded Disability Status Scale score. Psychological factors, such as focusing on bodily sensations and low sense of control play a role in the experience of fatigue in MS and CFS.

[Internal medicine and local anesthesia in dentistry. A review of possible side effects]. / Inwendige geneeskunde en lokale anesthesie in de tandheelkunde. Een overzicht van mogelijke bijwerkingen.

When using local anaesthesia the dentist may be confronted with a variety of side effects, either caused by the anaesthetic solution itself or its additives, including vasoconstrictive drugs such as epinephrine. Early recognition and treatment of these side-effects are essential. Even more important is the possible prevention of such side-effects by a properly taken medical history before using local anaesthesia.

Prognosis in chronic fatigue syndrome: a prospective study on the natural course.

OBJECTIVE: To determine spontaneous improvement after a follow up interval of 18 months in patients with chronic fatigue syndrome and to identify factors that predict improvement. METHODS: A longitudinal study was used. Of 298 initially assessed self referred patients fulfilling criteria for chronic fatigue syndrome, 246 patients completed self report questionnaires at follow up (response rate 83%). A multidimensional assessment method was used, measuring behavioural, emotional, cognitive, and social functioning. Comparison data from 53 healthy subjects matched for age, sex, and educational level were available. RESULTS: Three per cent of patients reported complete recovery and 17% reported improvement. At follow up, there were considerable problems at work and consumption of medication was high. Subjective improvement was confirmed by dimensional change: at follow up recovered patients had similar scores to healthy subjects and improved patients showed significant improvement on four out of seven outcome measures and had higher scores than healthy subjects in all dimensions. Sociodemographic variables or treatment by specialists and alternative practitioners did not predict improvement. Predictors of improvement were: subjective sense of control over symptoms, less fatigue, shorter duration of complaints, and a relative absence of physical attributions. CONCLUSION: The improvement rate in patients with a relatively long duration of complaints is small. Psychological factors are related to improvement, especially cognitive factors.

Randomised, double-blind, placebo-controlled study of fluoxetine in chronic fatigue syndrome.

BACKGROUND: No somatic treatment has been found to be effective for chronic fatigue syndrome (CFS). Antidepressant therapy is commonly used. Fluoxetine is recommended in preference to tricyclic agents because it has fewer sedative and autonomic nervous system effects. However, there have been no randomised, placebo-controlled, double-blind studies showing the effectiveness of antidepressant therapy in CFS. We have carried out such a study to assess the effect of fluoxetine in depressed and non-depressed CFS patients. METHODS: In this randomised, double-blind study, we recruited 44 patients to the depressed CFS group, and 52 to the non-depressed CFS group. In each group participants were randomly assigned to receive either fluoxetine (20 mg once daily) or placebo for 8 weeks. The effect of fluoxetine was assessed by questionnaires, self-observation lists, standard neuropsychological tests, and a motion-sensing device (Actometer), which were applied on the day treatment started and on the last day. FINDINGS: The two groups were well matched in terms of age, sex distribution, employment and marital status, and duration of CFS. There were no significant differences between the placebo and fluoxetine-treated groups in the change during the 8-week treatment period for any dimension of CFS. There was no change in subjective assessments of fatigue, severity of depression, functional impairment, sleep disturbances, neuropsychological function, cognitions, or physical activity in the depressed or the non-depressed subgroup. INTERPRETATION: Fluoxetine in a 20 mg daily dose does not have a beneficial effect on any characteristic of CFS. The lack of effect of fluoxetine on depressive symptoms in CFS suggests that processes underlying the presentation of depressive symptoms in CFS may differ from those in patients with major depressive disorder.

[Improvement in the internists' outpatient report using a time control system and systematic feedback by the general practitioner]. / Verbetering van de internistische polikliniekbrief door een tijdbewakingssysteem en door systematische terugkoppeling door de huisarts.

OBJECTIVE: To establish if the letters from internists contain the information wanted by the GP and if the quality of these letters can be improved by a time control system and by systematic feedback from the GP to the internist. DESIGN: Questionnaire study. SETTING: Outpatient clinic for General Internal Diseases, University Hospital Nijmegen. METHOD: The 284 GPs in the region were polled about their requirements for information in terms of speed and contents. Patient files were examined to find out to what extent the outpatient department met these requirements. The outpatient clinic physicians were informed of the findings. Subsequently a control system was introduced; every letter was accompanied by a postage-paid evaluation card inviting the GPs to comment. The findings obtained were reported back to the outpatient department physicians. RESULTS: GPs appreciated a preliminary report after the first outpatient visit (response rate: 70%). In the final report, they particularly wanted information on diagnosis, treatment, management to be conducted and information given to the patient. The control system accelerated final reporting. Of the evaluation cards 75% were returned; the explanation concerning diagnosis and treatment was experienced as sufficient, while mention of the information given to the patient was not always found satisfactory. CONCLUSION: The internists' letters did not optimally meet the GPs' need of information. A 'time control system' accelerated the final reporting on newly referred patients. A systematic feedback of the GPs' opinions on the quality of the letters improved the alignment of the information provided with the GPs' requirements.

Lymphocyte subsets, apoptosis, and cytokines in patients with chronic fatigue syndrome.

Whether immunologic abnormalities correlate with fatigue severity and functional impairment in chronic fatigue syndrome (CFS) was investigated. Blood mononuclear cells were immunophenotyped and circulating ex vivo-produced cytokines were measured in 76 CFS patients and 69 healthy matched controls. Expression of CD11b on CD8 cells was significantly decreased in CFS patients. However, the previously reported increased expression of CD38 and HLA-DR was not confirmed. There was no obvious difference in apoptosis in leukocyte cultures, circulating cytokines, and ex vivo production of interleukin (IL)-1 alpha and IL-1 receptor antagonist. Endotoxin-stimulated ex vivo production of tumor necrosis factor-alpha and IL-beta was significantly lower in CFS. The immunologic test results did not correlate with fatigue severity or psychologic well-being was measured by Checklist Individual Strength, Beck Depression Inventory, and Sickness Impact Profile. Thus, these immunologic tests cannot be used as diagnostic tools in individual CFS patients.

The relationship between complaint-related cognitions in referred patients with irritable bowel syndrome and subsequent health care seeking behaviour in primary care.

BACKGROUND: It is generally accepted that it is important to explore patients' beliefs and fears about the meaning of their symptoms during medical consultations. OBJECTIVE: To discover how referral behaviour of GPs and attention to dysfunctional cognitions of medical specialists affect the subsequent health care seeking behaviour of patients with irritable bowel syndrome. METHOD: Questionnaires were distributed to GPs and to doctors and patients at an outpatient clinic in the University Hospital of Nijmegen. RESULTS: The results of the present study indicate that doctors' attention to the complaint-related cognitions of IBS-patients is also related to a reduced use of medical health services in primary care. On the other hand, when referred IBS-patients continue to attribute their complaints to a somatic abnormality even after such an abnormality has been ruled out through extensive physical examinations, the subsequent use of medical health services in primary care is likely to increase. Moreover, GPs' referral behaviour appears to strengthen these dysfunctional somatic attributions in IBS-patients. CONCLUSION: These unfavorable consequences might be avoided by handling cognitions and anxiety more specifically during medical consultations in primary as well as secondary care.

Doctor-dependent changes in complaint-related cognitions and anxiety during medical consultations in functional abdominal complaints.

This study explored the changes in complaint-related cognitions and anxiety of 110 consecutive out-patients with functional abdominal complaints (irritable bowel syndrome), during a series of consultations. Patients' anxiety, fear of cancer, somatic attribution concerning intestines or stomach and catastrophizing cognitions appeared to diminish significantly during the consulting period. Positive changes in patients' psychological attribution and somatic attribution appeared to be related to doctors' correct perceptions of these attributions. Catastrophizing cognitions diminished significantly more when patients saw the same doctor throughout the consultations. As changes in attributions and catastrophizing cognitions appeared to be related to doctor-patient interaction, it is conceivable that doctors could learn to influence cognitions even more.