# Accurate, Thorough Information on ME (CFS)



## M&M (Jan 20, 2002)

From the Co-Cure mailing list, with full permission to forward to anyone, anywhere:


> quote:Information on Myalgic Encephalomyelitis (M.E.)/Chronic Fatigue Syndrome(CFS)What is CFS? What is M.E.?The term Chronic Fatigue Syndrome (CFS) was introduced in 1988 to describemedically unexplained, persistent or relapsing fatigue of new onset.CFS has come to include what has historically been known as MyalgicEncephalomyelitis (M.E.).CFS represents a broad diagnostic category and selects a heterogeneous(mixed) patient population, amalgamating disparate health problems thatcontain "fatigue" under the umbrella term CFS. Some patient groups adoptedthe term Chronic Fatigue Immune Dysfunction Syndrome (CFIDS) todifferentiate it from idiopathic chronic fatigue.M.E. is a more specific and appropriate diagnosis than chronic fatiguesyndrome, as it describes a specific condition with muscle and neurologicalsymptoms, not only the ubiquitous symptom of fatigue.M.E. is a distinct clinical entity that can be clearly defined by observablephysical signs and characteristic features (not merely by exclusion), themost distinctive being incapacitating exhaustion after even minimalexertion, and prolonged recovery time. More specifically, the fatigue inM.E. is exertion related (vs. "tired all the time"), with a significantlyprolonged recovery time, and all symptoms can be exacerbated by levels ofphysical, cognitive, sensory or emotional stress that would have been of noconsequence prior to the illness onset.M.E. is a systemic disease with many systemic features, but characterizedprimarily by central nervous system (CNS) dysfunction, of which fatigue,sleep disorders, autonomic dysfunction, cognitive dysfunction, endocrinedysfynction, proprioceptive dysfunction, sensory dysfunction etc. are amongthe many and varied manifestations. It is also characterized by what may bea marked variation and fluctuation of symptoms, both in occurrence andintensity.CFS and M.E. are currently classified in the WHO ICD-10 as a neurologicaldisorder (G.93.3 - Diseases of the Nervous System - Other disorders of thebrain and central nervous system).What's in a name?Terminology and usage is beyond preference or semantics, as it is impossibleto write about any illness, particularly one so complex, without attemptingto define and understand the various terms used to describe it.Currently both names/descriptions may be used, or sometimes may be usedinterchangeably, which has led to a great deal of confusion. OverallCFS/CFIDS is used in the U.S., while M.E. is still preferred by most ofEurope, Canada and Australia.Dr. Charles Lapp, board member of the American Association of ChronicFatigue syndrome (AACFS) and member of a federal HHS CFS advisory committee,states "One thing that we all seem to agree on is that the word "fatigue"needs to be removed from the name of the illness we call "chronic fatiguesyndrome." Just tell somebody that you have chronic fatigue syndrome, andthe first retort is, 'oh I have that too I'm just so tired.' The term"chronic fatigue," while descriptive of the most common symptom of thisillness is so vague and banal that it seems derisive and derogatory. The"fatigue" of this illness is so much more than just "tiredness." In factthere is no word in the English lexicon that describes the lack of stamina,the paucity of energy, the absolute malaise and turpitude that accompaniesthis illness."One symptom should not be the name, especially one so non-specific andnon-definable as fatigue, which is shared by nearly all illnesses bothphysical (neurologic, autoimmune, infectious, malignancies etc.) andpsychiatric, as well as being a normal physiological state; nor shouldfatigue be the defining feature, nor the basis for researching the illness.It is impossible to convey the seriousness of an illness whose name merelydenotes 'tiredness.'The prominent association of fatigue with psychiatric disorders has greatlycontributed to the erroneous psychological attributions of the illness, muchto the detriment of patients.This has led to the trivialization of the illness as little more than amanageable, unexplained fatigue state (rather than the prominent morespecific - and debilitating - neurological features of M.E), and themisperception that it may be treatable by little more than counseling, OTCmedications, antidepressants and lifestyle changes.Until the name/definition issues are resolved, a general worldwide consensushas been the interim adoption of the term M.E./CFS (to specifywhat some have recognized and referred to more specifically as "strictlydefined CFS" - which is what prior to 1988 was recognized as M.E.)M.E./CFS is a serious, complex illness with numerous systemic features.Based on clinical and scientific evidence, CFS/M.E. may be characterized asa CNS dysfunction, which offers the most plausible explanation for thediverse physical and neuropsychiatric symptoms, of which fatigue, NMH, sleepdisorders, etc. are among the many and varied manifestations.HistoryM.E. has been documented in the medical literature since 1934 in bothepidemic and sporadic forms and has been formally classified by the WorldHealth Organization (WHO) as a neurological disorder since 1969.There have been many recorded outbreaks of M.E. during the 20th century,which in the U.S. were initially referred to epidemic neuromyaesthenia. In1959 a comprehensive review paper was published by Dr. Donald Henderson (aCDC epidemiologist) and Dr. Alexis Shelakov (an NIH epidemiologist) in theNew England Journal of Medicine describing several outbreaks. Dr. Hendersonnoted: "The pattern of the epidemic, the absence of any common exposurefactors and the high incidence among medical and hospital personnel wereconsistent only with an infectious disease transmitted from person toperson.In 1988, what was historically known both as myalgic encephalomyelitis(M.E.) and as the well-documented epidemic neuromyasthenia was renamedï¿½Chronic Fatigue Syndromeï¿½ by a panel convened under the aegis of the CDC.CFS was redefined in 1994 and now has become a broad diagnostic category andcovers nearly anything with profound, chronic, unexplained fatigue. Littleepidemiology has been done since, as it is not feasible to confirm clustersof fatigue.How is CFS diagnosedCurrently the diagnosis is based on an international research casedefinition (Fukuda, 1994). CFS can be diagnosed if the patient meets thefollowing criteria with no alternative medical or psychiatric explanation:1.) Clinically evaluated, unexplained persistent or relapsing chronicfatigue that is of new or definite onset, is not the result of ongoingexertion, is not substantially alleviated by rest and results in asubstantial reduction in previous levels of functioning.2.) The concurrent occurrence of four or more of the following symptoms:substantial impairment of short-term memory or concentration, sore throat,tender lymph nodes, muscle pain, multi-joint pain without redness orswelling, headaches of a new type, pattern or severity, unrefreshing sleep,post exertional malaise lasting more than 24 hours. These symptoms must havepersisted or recurred during six or more months of illness and must not havepredated the fatigue.The CFS (Fukuda) definition was developed for research purposes and has beenproven inadequate for clinical purposes. The ever broadening definition ofCFS selects a mixed patient population, with the tendency to include peoplewith mild disability. The focus on fatigue and the vagueness of thedefinition makes it difficult to distinguish the pathological fatigue ofCFS/M.E. from ordinary fatigue or other fatiguing conditions.Patients may fulfill the loose CFS criteria who have "fatiguing" disordersother than M.E. and may include those with fatigue due to primary sleepdisorders, nutritional deficiencies, stress and a number of psychiatricconditions. And with the existence of different definitions of CFS, it hasthus come to mean different things to different people.It is the use of increasingly wider, less specific criteria and the focus onfatigue has created much confusion and misunderstanding during the pastdecade.Recently an international panel of experts, under the auspices ofHealthCanada, developed a Clinical Consensus Definition (MyalgicEncephalomyelitis/Chronic Fatigue Syndrome: Clinical Working CaseDefinition, Diagnostic and Treatment Protocols, Journal of Chronic FatigueSyndrome, Vol. 11 (1) 2003.) This definition is far superior to the variousother CFS definitions and has been welcomed internationally. It includes thehallmark features of M.E. (optional in the CFS definition) and neurologicaland cardiovascular symptoms which more accurately represent the truesymptomatology and manifestations of the illness than other current (fatiguebased) definitions. This represents the current best practice guidelines fortreating and managing M.E./CFS.Other symptoms/characteristicsSymptoms also frequently include pain, vertigo (dizziness), visualdisturbances, photophobia, spacial disorientation, disequilibrium, nausea,paresthesias (numbness and tingling), dyspnea, emotional lability (moodswings), tachycardia, sleep disorders (hypersomnia or insomnia), low gradefever, intolerance to alcohol, seizure activity.Fragmented sleep (periods of wakefulness throughout the sleep period) andlack of deep-stage sleep are very common. True insomnia (inability to fallasleep) is uncommon, although patients may have delayed sleep onset becauseof a disrupted circadian rhythm (resulting in reversal of nighttime sleeppattern).Neurocognitive dysfunction may include cognitive, motor and perceptualdisturbances. The cognitive dysfunction may be more variable but may bepronounced, and is sometimes referred to as "brain fog," or confusion. Italso includes slow information processing speed, trouble with speaking,writing, reading and short term memory.There may be an "overload phenomenon," where patients may be very sensitiveto light, sounds, odor. The variable sensory, cognitive, emotional or motoroverload may precipitate a "crash," where the patient experiences a severe,incapacitating physical/mental fatigue or weakness.Similar Medical ConditionsM.E./CFS is similar to other illnesses such as multiple sclerosis, lupus,Lyme disease, mononucleosis, Gulf War Syndrome. CFS may overlap or co-existwith fibromyalgia, multiple chemical sensitivities, irritable bowelsyndrome.However, these may co-exist with other conditions as well and are viewed asseparate entities which stand on their own, regardless of whether a personhas other medical problems. Even though there are similarities or overlapdoes not mean that they represent the same etiological or pathobiologicalprocess.Psychiatric ConditionsAlthough some symptoms may be similar, M.E./CFS is not a psychiatricillness. There are several objective findings that differentiate CFS/M.E.from psychiatric conditions and indicate that it is biologically, notpsychologically determined.According to Harvard University professor Dr. Anthony Komaroff: "Insummary, there is now considerable evidence of an underlying biologicalprocess in most patients (which) is inconsistent with the hypothesis that(the illness) involves symptoms that are only imagined or amplified becauseof underlying psychiatric distress. It is time to put that hypothesis torest."The prevalence rates of clinically significant depression in patients withCFS are not much different from those reported in other medically illpopulations.Abnormalities associated with CFS/M.E.SPECT scans have demonstrated decreased cerebral blood flow, PET scans haveshown decreased brain metabolism; MRI scans have shown the presence of smallwhite matter lesions. These abnormalities have been shown to correlate withclinical status. The abnormalities in M.E./CFS patients most closelyresemble those seen in AIDS encephalopathy.Neuroendocrine abnormalities have been found in thehypothalamic-pituitary-adrenal (HPA) axis. Hypothalamic dysfunction causesdecreased cortisol; thus patients react extremely adversely to stress.Autonomic nervous system dysfunction includes orthostatic intolerance,neurally-mediated hypotension and postural tachycardia syndrome. Manypatients have low blood volume.The immune system abnormalities mimic the immune pattern seen in viralinfections. Specific findings include increased numbers of activatedcytotoxic T cells, low natural killer cell function, and elevated immunecomplexes. A large University of Miami study found that the array ofimmunological defects suggest that M.E./CFS is a form of acquiredimmunodefficiency.A more specific immune system abnormality has been discovered in M.E./CFS ofincreased activity and dysfunction of the 2-5A RNase-L antiviral pathway inlymphocytes. The dysregulation of the RNase-L pathway supports thehypothesis that viral infection may play a role in the pathogenesis of theillness. Patients with CFS/M.E. were very different from patients with majordepression, fibromyalgia or healthy controls.Sub-optimal cardiac function and abnormal cardiovascular responses have alsobeen demonstrated. One study found found left-ventricular dysfunctionfollowing exertion and orthostatic stress in patients with M.E./CFS and thatthe heart failed to pump enough blood following exertion and uprightposture. Dr. A. Martin Lerner discovered persistent viral infection in theheart, causing left-ventricular dysfunction, resulting in exerciseintolerance.(Exercise, in turn, worsens the cardiac dysfunction.) Thedisease in the early stages is consistent with a dilated cardiomyopathy thatin later stages might result in progressive, end-stage dilatedcardiomyopathy, a type of heart failure.Abnormal laboratory values do occur among M.E./CFS patients. These mayinclude: Immune complexes, Immunoglobulin G, low level Antinuclear antibodytiter, Alkaline phosphatase, Cholesterol, Lactate dehydrogenase, Atypicallymphocyte count.These tests may support a diagnosis of M.E./CFS although they lacksufficient sensitivity to be considered diagnostic tests, but can be used asobjective markers of illness to support disability claims.More recently, the University of Hawaii discovered the ocurrence of anendogenous lipid, similar in structure to ciguatoxin, in M.E./CFS. Thechronic phase lipids (CLP) may be comparable to "acute phase proteins" suchas C-reative protein, which increase in diseases such as inflammation andtrauma. The test for CPL may be used to confirm the diagnosis. The testingprocedure is on the NCF website at http://www.ncf-net.org/ Infectious AgentsThat fatigue occurs in infectious illnesses has been well established. Manypatients suffer from sore throats, fever, tender lymph nodes, whichaccompany diseases caused by infectious agents. Several retrospectivestudies have shown that infectious agents play an important role in theonset and maintenance of M.E./CFS. The role of infections remain unclear asto whether they may be causative, co-factor or opportunistic.M.E./CFS has been associated with several infectious agents includingMycoplasma, Rickettsia, Chlamydia, Borrelia. Several viruses have beenassociated with M.E./CFS, including: herpes virus, particularly human herpesvirus 6 (HHV-6),Epstein-Barr virus (which causes infectious mononucleosis),Cytomegalovirus and Coxsackie viruses. Indirect immunological evidence alsosupports the role of persistent viral infection.These infections have been found to play an important role in M.E./CFS andantimicrobial therapy to suppress chronic infections has resulted inimprovement. Whether or not they are causal, these agents may contribute tothe morbidity and warrant appropriate testing and treatment.What causes M.E./CFSThe precise cause is unknown but published studies continue to demonstratethat the basis lies in abnormalities of the central nervous system (CNS) andimmune system, both of which influence and alter the function of the other.A large study of the original Incline Village outbreak in the early 1980'sreported that M.E./CFS represents "an immunologically mediated inflammatoryprocess of the CNS."Due to its similarity to chronic mononucleosis, CFS was initially thought tobe caused by a virus infection, most probably Epstein-Barr virus (EBV).However EBV activation (along with reactivation of other latent viruses) isnow considered a consequence rather than the cause.Based on physical and clinical evidence, many experts believe that virusesare associated with M.E./CFS and may be involved in causing the illness.There is evidence from several controlled studies of the reactivation ofseveral chronic viral infections in M.E./CFS. M.E./CFS has been documentedfollowing a variety of acute infections with viruses (such as followingacute infectious mononucleosis), bacteria (such as followingproperly-treated Lyme disease), and other microbial infections (such asfollowing Q fever).Dr. Anthony Komaroff, international M.E./CFS expert and Harvard researcher,notes the relationship between the CNS abnormalities and infection, forwhich there is considerable evidence. The article published in the Journalof Internal Medicine states: "one interesting hypothesis that linksinfection with CNS dysfunction is the possibility of a chronic viralencephalitis as an initiator of a process that leads to CFS. It is knownthat viruses in animals and humans can affect the HPA axis, thus makinginfectious agents that cause CNS disturbances of particular interest."CFS research is conducted at CDC by the Division of Viral and RickettsialDiseases, National Center for Infectious Diseases.Is CFS/M.E. contagiousThorough transmissibility studies have not been conducted. CFS/M.E. has beenreported in multiple family members. Some studies have shown geneticlinkages, however, genetic basis is not consistent with the epidemiology ofM.E./CFS Genetic diseases slowly increase in the population over time, notas a sudden explosion of cases, as happened with M.E./CFS in the early-mid1980's.There have been numerous outbreaks of M.E. worldwide. A largeepidemiological investigation was conducted on a 1956 outbreak in PuntaGorda, Florida by Chief of CDC's Epidemic Intelligence Service Dr. D.A.Henderson (who is revered for spearheading the successful effort toeliminate smallpox). According to Dr. Henderson, "The pattern of theepidemic, the apparent absence of any common exposure factors and the highincidence of illness among medical and hospital personnel were consistentonly with an infectious disease transmitted from person to person... We wereable to postulate the general nature of the micro-organism. It was probablya virus."According to the Red Cross, patients with autoimmune disease, includingsystemic lupus erythematosus and multiple sclerosis, are not eligible todonate blood. Chronic fatigue syndrome appears under chronic illnesses.Most chronic illnesses are acceptable as long as you feel well. Chronicfatigue syndrome, fibromyalgia, rheumatoid arthritis, ulcerative colitis andCrohn's Disease are not specific disqualifications.A CDC official advised an inquiring M.E./CFS patient to refrain fromdonating blood or organs until the cause or mode of transmission is betterunderstood. It has been shown that patients may harbor infectious agents intheir blood. Blood donation may also exacerbate symptoms due to low bloodvolume.Prevalence and risk factorsRecent data has established the importance of M.E./CFS as a serious publichealth concern. A Chicago study estimated that 800,000 adults in the U.S.have CFS/M.E. More importantly, 90% have never been appropriately diagnosed.This is a public health crisis.Initial research suggested that M.E./CFS was a relatively rare disorder andaffected mainly upper middle class white women. For some time there wereeven disputes in medical circles about whether M.E./CFS existed or if it wasa "real" illness, even though it is formally recognized by the CDC, NIH,SSA, WHO. It was initially disparagingly dubbed "Yuppie flu," giving theimpression that it affected mainly overachievers who couldn't handle stressand burned out, which hardly seemed to warrant much attention or concern.M.E./CFS is not limited to any specific race, age or socioeconomic group.Contrary to the "yuppie flu" myth, this study also showed the illness to bewide-spread in low-income and minority communities. It is most commonminorities, with Latinos and Mexican Americans exhibiting higher rates thanCaucasians.Onset and prognosisThe clinical course of M.E./CFS varies considerably. There is a fullspectrum of disease severity, with some patients being mildly affected whileothers are in wheelchairs or completely bedridden. The clinical outcome ofM.E./CFS usually takes one of three courses: recovery/improvement,relapsing/remitting course, and permanent incapacity or progressivedeterioration of symptoms. Studies have shown that recovery is uncommon,with only 4% of patients recovering and 39% showing some symptom improvementafter four years.Those who obtain an early diagnosis, and receive appropriate care andmanagement, tend to be the ones who make the most significant progress.Australian researchers found that M.E./CFS patients had more dysfunctionthan those with M.S., that the degree of impairment was more severe than inend stage renal and heart disease, and that only in terminally ill cancerand stroke patients was the sickness impact profile (SIP) higher than inM.E./CFS.Twenty five percent of the severely affected are home or bed-bound, many areunable to manage a visit to the doctor's office and thus are often unable toreceive any medical care or services. Many are abandoned by the medicalcommunity, their family and friends and society in general, become isolatedand remain ignored and invisible.Dr. Paul Cheney stated before an FDA Scientific Advisory Committee: "Theworst cases have both an MS-like and an AIDS-like clinical appearance. Themost difficult thing to treat is the severe pain. Most have abnormalneurological examination. 80% of cases are unable to work or attend school.We admit regularly to hospital with an inability to care for self."Suicide rates are high and seem to be related to the current climate ofdisbelief and rejection and inability to receive adequate support andservices.The National CFIDS foundation has a Memorial list of M.E./CFS patients whohave died, most recognizable causes being cancer and heart disease (a paperis under review). After decades of illness, death is known to occur from endorgan damage.TreatmentTreatment has been palliative at best, based on trial and error applicationof anecdotal evidence and has been mostly limited to the relieve of specificsymptoms. This has been largely inadequate. M.E./CFS patients may beextremely sensitive to many medications, so only low doses should be giveninitially and still may produce intolerable side effects.The testing and recognition of underlying abnormalities offers the mosteffective treatment. For example, treating hypothalamic dysfunction whichproduces poor sleep, low hormone levels, and treating the effects of immunedysfunction/chronic infections (immune modulation to shift from Th2 to Th1predominance, enhance NK cell activity, reduce pro-inflammatory cytokines,antivirals to reduce viral reactivation etc.) have proven the mostsuccessful.There are currently no FDA-approved medications for use in treatingM.E./CFS. There are, however, a number of medications that may be helpful,even though some are recommended for effects that may be unrelated to theirprimary use. These include antifungals, antihistamines, antivirals,antibiotics, CNS depressants (or stimulants), immunoglobulins, cardiacmedications, anti-inflammatories, anticonvulsants, expectorants andantidepressants.Vaccine RecommendationsM.E./CFS patients should generally not be offered live vaccines because ofrisk of relapse.Flu vaccinations are generally not recommended to persons with M.E./CFSunless patients have tolerated them well in the past or have other medicalcomplications in addition to M.E./CFS. Flu vaccines may cause seriousrelapses, and many patients fail to sero-convert (develop antibodies) to thevaccination. Thus, patients may have side effects in addition to a relapseof symptoms, but may not even develop immunity.Since smallpox vaccine is a live vaccinia virus, many experts recommend thatpersons with M.E./CFS not take smallpox vaccine, due to high incidence ofimmune dysfunction, autoimmune phenomenon, and hypogammaglobulinemia.Economic burdenM.E./CFS costs the U.S. more than $9 billion each year in lost productivity,or about $20,000 per person annually, not even including healthcare costs,according to a CDC study published in the journal Cost Effectiveness andResource Allocation. About a quarter of those with chronic fatigue syndrome,or CFS/M.E., aren't able to work at all, and those who do continue to worklose about one-third of their income, the report said.M.E./CFS and ChildrenFew pediatric studies have been done, yet is is well established thatchildren and adolescents get M.E./CFS Minimal attention has been paid tocritical features of M.E./CFS in children and is thus often unrecognized inchildren. Children with M.E./CFS are frequently dismissed as depressed orschool phobic, and thus remain unable to receive proper care oraccommodations for their illness.The effects can be devastating in children, resulting in serious disruptionof their education and social development. Research conducted in the UK on alarge school population showed that 51% of all children on long termsickness absence had M.E./CFS, overturning the myth that it is extremelyrare in children. A national report done by the UK Department of Health,clearly states that all children who are moderate-severely affected willrequire home tutoring or distance learning and should not be expected toattend school, which can cause severe relapses.CBTCBT is a form of psychotherapy focused primarily on changing the way wethink in order to reduce the understandable feelings of fear, depression andanxiety associated with chronic illnesses.CBT has often been misrepresented, claiming that it is an effectivetreatment for the condition as a whole - which goes way beyond the evidence.In terms of scientific evidence, the CBT trials have generally not includedmeasures of symptoms other than fatigue and emotional distress. These trialshave little relationship to patients with organic immunological andneurological abnormalities. While there may be improvement in fatigue oremotional distress, it does not improve overall activity or physicalfunctioning.The complexity of CBT studies, their varied inclusion and exclusioncriteria, issues of proper blinding, and the subjective means used for mostevaluations seriously questions the validity of their results.The literature is replete with psychiatric studies on CFS (fatigue states)that have no bearing o M.E./CFS. It is not possible to effectively treatany neurological condition by using passive forms of psychologicalcounseling.The exercise questionAccording to the seminal work on M.E. of Dr. Melvin Ramsay, "The degree ofphysical incapacity varies greatly, but the dominant clinical feature ofprofound fatigue is directly related the length of time the patient persistsin physical effort after its onset; put in another way, those patients whoare given a period of enforced rest from the onset have the best prognosis."It has been demonstrated that graded exercise was either of little or no useto the majority of patients, and that the use graded exercise on theseverely affected was indeed harmful. In a British study, 1,214 of 2,338patients had tried graded exercise. Of these, 417 found it to be helpful,197 reported no change and 610 (50%) indicated that it made their conditionworse. This was the highest negative rating of any of the pharmacological ornon-pharmacological interventions covered in the questionnaire (and mayexplain the high drop out rates found in some of these programs).Exercise has been shown not to be an effective form of treatment, while ithas also been confirmed that there may be ongoing neurological, endocrine,immunological, and cardiovascular abnormalities which are causing thesymptoms of M.E./CFS. Exercise will not treat or improve theseabnormalities and in fact, will exacerbate symptoms that are caused by suchabnormalities. (Dr. A. Martin Lerner discovered that some patients hadpersistent viral infections in the heart, causing left-ventriculardysfunction, resulting in exercise intolerance. Exercise worsens thecardiac dysfunction.)Even minor activity, either physical or mental, may cause a significantworsening of symptoms. The recommended management for M.E./CFS is notexercise but "activity" management (sometimes referred to as pacing), whichis to conserve energy, not to expend it. These are very different concepts,and pacing is intended to prevent overexertion and relapse, not forimprovement. On average, M.E./CFS patients have been shown to befunctioning dangerously close to their energy limits, and increasingactivity is counter-productive.If even trivial activity can exacerbate symptoms, then exercise is not aneffective treatment.Jill McLaughlinReferencesDowsett, E. G., Ramsay, A. M., McCartney, R. A., & Bell E. J. (1990).Myalgic Encephalomyelitis - a persistent enteroviral infection? PostgraduateMedical Journal, 66, 526-530.Ramsay, M. (1988). Myalgic encephalomyelitis and postviral fatigue states:The sage of Royal Free disease. 2nd edition. Gower Medical Publishing,London.Carruthers, B.M., Jain, A.K., DeMeirleir, K.L., Peterson, D.L., Klimas,N.G., Lerner, A.M., Bested, A.C., Flor-Henry, P., Joshi, P., Powles, A.C.P.,Sherkey, J.A., & van de Sande, M.I. Myalgic encephalomyelitis/chronicfatigue syndrome: Clinical working case definition, diagnostic andtreatments protocols. Journal of Chronic Fatigue Syndrome.Poskanzer D.C., Henderson D.A., et al. Epidemic Neuromyasthenia: Outbreak inPunta Gorda, Florida. NEMJ 1959; 257:356-364.Henderson, D.A., Shelakov A. Epidemic Neuromyasthenia - clinical syndrome.NEJM 1959; 15:757-764.Acheson E.D. The clinical syndrome variously called "benign MyalgicEncephalomyelitis," "Iceland Disease," and "Epidemic Neuromyasthena." Am JMed 1959; 26:569.Schwartz R.B. Garada B.M. et el. Detection of intracranial anormalities inpatients with CFS: comparison or MR imaging and SPECT. Am J Roentgenol 1994April 162 (4): 935-941.Hokama Y., Uto G.A., Palafox NA, Chronic phase lipids in sera of chronicfatigue syndrome (CFS), chronic ciguatera fish poisoning (CCFP), hepatitisB, and cancer with antigenic epitope resembling ciguatoxin, as assessed withMAb-CTX J Clin Lab Anal. 2003;17(4):132-9.Lerner, A.M."Editorial Response: Microbial Persistence and IdiopathicDilated Cardiomyopathy." Clinical Infectious Diseases (1999):29:526-7.Lerner, A. M., Goldstein, J., O'Neill W., et al."Cardiac involvement inpatients with chronic fatigue syndrome as documented with Holter and biopsydata in Birmingham, Michigan, 1991-1993." Inf Dis in Clin Pract, 1997;6:327-333.Jason, L.A., Holbert, C., Torres-Harding, S., & Taylor, R.R. Stigma andchronic fatigue syndrome: Surveying a name change. Journal of DisabilityPolicy Studies.Jason, L.A., Eisele, H., & Taylor, R.R. (2001). Assessing attitudes towardnew names for chronic fatigue syndrome. Evaluation and the HealthProfessions, 24, 424-435.Jason, L.A., Taylor, R.R., Stepanek, Z., & Plioplys, S. (2001). Attitudesregarding chronic fatigue syndrome: The importance of a name. Journal ofHealth Psychology, 6, 61-71.Komaroff A.L., Buchwald D. Symptoms and signs of chronic fatigue syndrome.Rev Infect Dis1991;13(Suppl 1):S8-11Jason, L.A., Taylor, R.R., Kennedy, C.L., Jordan, K., Song, S., Johnson, D.,& Torres, S. (2000). Chronic fatigue syndrome: Sociodemographic subtypes ina community-based sample. Evaluation and the Health Professions, 23,243-263.Tan, E.M., Sugiura, K., & Gupta, S. (2002). The case definition of chronicfatigue syndrome. Journal of Clinical Immunology, 22, 8-12.Epidemiological study of an epidemic diagnosed as poliomyelitis occurringamong the personnel of Los Angeles County General Hospital during thesummer of 1934. Gilliam AG. Public Health Bulletin, US Treasury DepartmentNo.240, 1938Haley, R.W., Kurt, T.L., & Hom, J. (1997). Is there a Gulf War Syndrome?Journal of the American Medical Association, 277 (3), 215-222.Buchwald D., Cheney P.R., Peterson D.L. et. al. A chronic illnesscharcterized by fatigue, neurological and immunological disorders and activehuman herpes virus 6infection. Ann of Intern Med 1992; 116 (2): 103-113.Klimas, N. et.al. Immunological Abnormalities in Chronic Fatigue Syndrome.Journal of Clinical microbiology, June 1990:1403-1410.Suhadolnik R.S., Reichenbach N.I., et. al., Changes in the 2-5 Asynthetase/RNase-L antiviral defense pathway in CFS. JCFS 1999;5(2?4):223-242.DeMeirleir, K. DeBecker P. et al., Abstract. Presented at the SydneyAustralia CFS conference 1999.Peckerman A., LaManca J.J., Dahl K.A., Chemitiganti R., Qureishi B.,Natelson B.H. "Abnormal impedance cardiography predicts symptom severity inchronic fatigue syndrome." Am J Med Sci. 2003 Aug;326(2):55-60.Arnold Peckerman, PhD, John J. LaManca, PhD, Bushra Qureishi, MD, KristinaA. Dahl, MD, Roseli Golfetti, PhD, Yoshiharu Yamamoto, PhD and Benjamin H.Natelson, "Baroreceptor Reflex and Integrative Stress Responses in ChronicFatigue Syndrome." Psychosomatic Medicine 65:889-895 (2003)Fukuda K., Straus S.E. et.al. CFS: a comprehensive approach to itsdefinition and study. Ann Intern Med 1994; 121:953-959.Dowsett E.G., Colby J. Long Term sickness absence due to CFS/M.WE. in UKschools: an epidemiological study with medical and educational imlications.JCFS 1997; 3(2):29-42.Scheweitzer R., Kelly B et.al., Quality of Life in CFS. Psychosom Med 1996;58:50-57.Streeton, H.P., Thomas d., Bell D.S., The role of orthostatic hypotension,orthostatic tachycardia and subnormal erythrocyte volume in the pathogenesisof CFS. Am J Med Sci 2000 July; 30(1) 1-8.Lange G., Wang S. Neuroimaging in CFS. Am J Med 1998;105(3A;50S-53S.Hyde B.M., Bastien s.. The Clinical and Scientific Sasis of MyalgicEncephalomyelitis/chronic Fatigue Syndrome. Then Nightengale ResearchFoundation, Ottawa, Canada.Sandman C.A., Barron J.L., et. al. Memory deficits associated with CFS.Biol Psychiat 1993; 33:618-638.Patarca-Montero R., Mark T., et.al. The immunology of chronic fatiguesyndrome. JCFS 2000; 6(3/4):69-107.Sources also include web site information and articles by Dr. EllenGoudsmit, Dr. Derek Enlander, Dr. Jacob Teitelbaum, Dr. Byron Hyde, Dr.Maryann Spurgin, Dr. Betty Dowsett, Dr. Charles Lapp.


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## M&M (Jan 20, 2002)

Bump for Miasue


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