Jason: Frequency and content analysis of CFS in medical textbooks

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Fred Springfield to CO-CURE today

Frequency and content analysis of CFS in medical textbooks

Journal: Australian Journal of Primary Health, 16, 174-178.

Jason, L.A., Paavola, E., Porter, N., & Morello, M. (2010).

Affiliation: DePaul University, Center for Community Research, 990 W. Fullerton Avenue, Suite 3100, Chicago, IL 60614, USA. Email: <ljason@depaul.edu>

Abstract.
Text books are a cornerstone in the training of medical staff and students, and they are an important source of references and reviews for these professionals. The objective of this study was to determine both the quantity and quality of chronic fatigue syndrome (CFS) information included in medical texts.

After reviewing 119 medical text books from various medical specialties, we found that 48 (40.3%) of the medical text books included information on
CFS.

However, among the 129 527 total pages within these medical text books, the CFS content was presented on only 116.3 (0.090%) pages. Other illnesses that are less prevalent, such as multiple sclerosis and Lyme disease, were more frequently represented in medical text books.

These findings suggest that the topic of CFS is underreported in published medical text books.
 

Tammie

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so quantity of info is lacking, but what about quality......how many of those texts actually have accurate info in them? I'm betting probably near zero

if they are all writing about GET/CBT etc, the less published the better (of course I'd love to see quality AND quantity)
 

gracenote

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I have access to nine online medical textbooks currently being sold. Here are three of the texts.

501 HUMAN DISEASES

Author: David Mullins, PhD
Publisher: Thomson Delmar
Publication Date: 2006


CHRONIC FATIGUE SYNDROME

Description

Chronic fatigue syndrome is a debilitating disorder characterized by profound fatigue that is not improved by bed rest and that worsens with physical or mental activity (Chronic fatigue syndrome, 2003).

Signs and Symptoms

Nonspecific symptoms may include weakness, muscle pain, impaired memory and concentration, and insomnia.

Treatment

Because the cause of chronic fatigue syndrome is unknown, treatment is aimed at relief of specific symptoms. Pharmaceutical treatment may include antidepressants, stimulants, anxiolytic agents, NSAIDS (e.g., aspirin and ibuprofen), and medications to affect sleep patterns.

Testing

Currently, to be diagnosed with chronic fatigue syndrome, a person must (1) have severe chronic fatigue of at least six months duration with other known medical conditions excluded by clinical diagnosis, and (2) concurrently have four or more of the following symptoms:
substantial impairment in short-term memory or concentration
sore throat
tender lymph nodes
muscle pain
multijoint pain without swelling or redness
headaches of a new type, pattern, or severity
unrefreshing sleep
postexertional fatigue lasting more than 24 hours​
The symptoms must have persisted for six or more consecutive months of illness and must not have predated the fatigue.
ADOLESCENT HEALTH CARE

Author: Lawrence Neinstein, MD, FACP
Publication Date: 2008

CHRONIC FATIGUE SYNDROME

CFS is a poorly understood and often controversial diagnosis that is seen mostly in adults but has increasingly been reported in adolescents. It involves chronic and debilitating fatigue seen in association with other symptoms. Details of this syndrome, as seen in adolescents, are as follows:

Definition
The Centers for Disease Control and Prevention has developed a working definition of CFS (Fukuda et al., 1994):
Fatigue of at least 6 months duration
Limits the individual to 50% of premorbid activity levels
May be persistent or recurrent
No other cause found to account for the fatigue
Additional symptoms (four or more are required to meet the criteria for CFS)
Recurrent pharyngitis
Tender lymph nodes
New-onset headaches
Impaired memory or concentration
Joint pains
Muscle pains
Nonrefreshing sleep
Postexertion fatigue​

Epidemiology
(includes chart)

Studies in adults and adolescents have shown the following:

Symptoms
Patients often have many symptoms of CFS simultaneously. One study of 59 children and adolescents showed the following symptoms (Krilov et al., 1998):

Fatigue 100%
Headache 74%
Sore throat 59%
Abdominal pain 48%
Fever 36%
Impaired cognition 33%
Myalgia 31%
Diarrhea 29%
Adenopathy 29%
Anorexia 28%
Nausea or vomiting 26%
Dizziness 17%
Arthralgia 17%
Sweats 9%
Chills 7%
Depression 7%​

Etiology
No specific etiology has been determined to be the cause of the CFS. Many possibilities have been considered. It is likely that the underlying cause may be a combination of factors, including an acute infectious illness that acts as a precipitant, a background of psychological distress, and an underlying physiological vulnerability (in the cardiovascular, neurological, endocrine, and/or immune systems). It is also likely that no two individuals with CFS have exactly the same relative ratio in the combination of underlying factors. Etiologies that have been considered include the following:
Infection
Several infectious diseases, most notably Epstein-Barr virus (EBV) infection and influenza, can serve as the precipitant for the onset of CFS. In other parts of the world, other viral infections have been implicated as triggers for CFS.
Any acute illnesses can cause an exacerbation of symptoms during the course of the syndrome.
No specific infectious agent has been found to account for continuation of the symptoms.

Cardiovascular system
Orthostatic symptoms are common in patients with CFS (Stewart et al., 1999a).
Tilt-table testing is often positive in patients with CFS.
Underlying cardiovascular instability, in those with a tendency toward hypotension, may be a factor in the cause of CFS.

Endocrine system
Decreased hypothalamic-pituitary-adrenal axis function has been suspected as an etiology in CFS but never clearly documented (McKenzie et al., 1998).
No other endocrine disorders have been consistently demonstrated in CFS.

Neurological
Headaches and impaired cognition are prominent symptoms in many patients with CFS.
Computed tomography (CT) scans and magnetic resonance imaging (MRI) do not show abnormalities in patients with CFS.
No other reproducible neurological abnormalities have been found to be a cause of CFS.

Immune function
Studies have shown in vitro abnormalities in lymphocyte function and cytokine production in CFS (Conti et al., 1998).
Reproducible abnormalities and opportunistic infections have not been found.
Treatment with immunoglobulins and other immune modulators have not shown clear benefits in CFS.

Depression
A history of depression is found in many adults with CFS; depression may create a psychological vulnerability necessary for the onset of CFS.
Depression may be one physiological consequence of changes in the brain that occur in CFS.
Depression may be a natural reaction to feeling ill and fatigued for a long time.
Some have suggested that CFS is merely an alternate expression of depression.
There is substantial overlap in the symptoms of CFS and depression leading to the possibility that some patients with depression will be misdiagnosed as having CFS and vice versa.

Other psychological variables
Separation anxiety and/or school phobia may be a factor in some children and adolescents with CFS.
Some have considered CFS to be in the realm of conversion reaction.​
Psychosomatic symptoms may be found premorbidly in some children and adolescents with CFS.
HARRISONS MANUAL OF MEDICINE

Author: Anthony Fauci, MD, Eugene Braunwald, MD, Dennis Kasper, MD, et al.
Publisher: McGraw Hill
Publication Date: 2009


CHRONIC FATIGUE SYNDROME

Chronic fatigue syndrome (CFS) is characterized by debilitating fatigue and several associated physical, constitutional, and neuropsychological complaints. Pts are twice as likely to be women as men and are generally 2545 years old. The CDC has developed diagnostic criteria for CFS based upon symptoms and the exclusion of other illnesses (Table 60-2). The cause is uncertain, although clinical manifestations often follow a viral illness. Many studies have attempted, without success, to link CFS to infection with EBV, a retrovirus, or an enterovirus. Depression is present in half to two-thirds of pts, and some experts believe that CFS is fundamentally a psychiatric disorder.

CFS remains a diagnosis of exclusion, and no laboratory test can establish the diagnosis or measure its severity. Fortunately, CFS does not appear to progress. On the contrary, many pts experience gradual improvement, and a minority recover fully.

NSAIDs alleviate headache, diffuse pain, and feverishness. Antihistamines or decongestants may be helpful for symptoms of rhinitis and sinusitis. Although the pt may be averse to psychiatric diagnoses, features of depression and anxiety may justify treatment. Nonsedating antidepressants improve mood and disordered sleep and may attenuate the fatigue.
 

gracenote

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Here is another one.

CURRENT MEDICAL DIAGNOSIS & TREATMENT

Author: Stephen McPhee, MD, Maxine Papadakis, MD
Publisher: McGraw Hill
Publication Date: 2009

FATIGUE & CHRONIC FATIGUE SYNDROME

GENERAL CONSIDERATIONS

As an isolated symptom, fatigue accounts for 13% of visits to generalists. The symptom of fatigue may be less well defined and explained by patients than symptoms associated with specific functions. Fatigue or lassitude and the closely related complaints of weakness, tiredness, and lethargy are often attributed to overexertion, poor physical conditioning, sleep disturbance, obesity, undernutrition, and emotional problems. A history of the patients daily living and working habits may obviate the need for extensive and unproductive diagnostic studies.

CLINICAL FINDINGS

A. Fatigue

Clinically relevant fatigue is composed of three major components: generalized weakness (difficulty in initiating activities); easy fatigability (difficulty in completing activities); and mental fatigue (difficulty with concentration and memory). Important diseases that can cause fatigue include hyperthyroidism and hypothyroidism, CHF, infections (endocarditis, hepatitis), COPD, sleep apnea, anemia, autoimmune disorders, and cancer. Alcoholism, drug side effects such as from sedatives and β-blockers, and psychological conditions (such as insomnia, depression, and somatization disorder) are other causes. Common outpatient infective causes include mononucleosis and sinusitis. These conditions are usually associated with other characteristic signs, but patients may emphasize fatigue and not reveal their other symptoms unless directly asked. The lifetime prevalence of significant fatigue (present for at least 2 weeks) is about 25%. Fatigue of unknown cause or related to psychiatric illness exceeds that due to physical illness, injury, medications, drugs, or alcohol. Psychiatric disorders associated with fatigue include depression, dysthymia, somatoform disorders, panic attack, and alcohol abuse. Prolonged fatigue is a central feature of several syndromes, such as irritable bowel syndrome and anxiety.

B. Chronic Fatigue Syndrome

A working case definition of chronic fatigue syndrome indicates that it is not a homogeneous abnormality, and there is no single pathogenic mechanism (Figure 22). No physical finding or laboratory test can be used to confirm the diagnosis of this disorder.
With regard to its pathophysiology, early theories postulated an infectious or immune dysregulation mechanism. Persons with confirmed chronic fatigue syndrome report a much greater frequency of childhood trauma and psychopathology and demonstrate higher levels of emotional instability and self-reported stress than non-fatigued controls. Neuropsychological, neuroendocrine, and brain imaging studies have confirmed the occurrence of neurobiologic abnormalities in most patients. Sleep disorders have been reported in 4080% of patients with chronic fatigue syndrome, but their treatment has provided only modest benefit, suggesting that it is an effect rather than a cause of the fatigue. MRI scans may show brain abnormalities on T2-weighted imageschiefly small, punctate, sub-cortical white matter hyperintensities, predominantly in the frontal lobes. Veterans of the Gulf War show a tenfold greater incidence of chronic fatigue syndrome compared with nondeployed military personnel.

In evaluating chronic fatigue, after the history and physical examination process is completed, standard investigation includes complete blood count, erythrocyte sedimentation rate, serum chemistriesblood urea nitrogen (BUN), electrolytes, glucose, creatinine, and calcium; liver and thyroid function testsantinuclear antibody, urinalysis, and tuberculin skin test; and screening questionnaires for psychiatric disorders. Other tests to be performed as clinically indicated are serum cortisol, rheumatoid factor, immunoglobulin levels, Lyme serology in endemic areas, and tests for HIV antibody. More extensive testing is usually unhelpful, including antibody to Epstein-Barr virus. There may be an abnormally high rate of postural hypotension; some of these patients report response to increases in dietary sodium as well as antihypotensive agents such as fludrocortisone, 0.1 mg/d.

TREATMENT

A. Fatigue

Management of fatigue involves identification and treatment of conditions that contribute to fatigue, such as cancer, pain, depression, disordered sleep, weight loss, and anemia. Resistance training and aerobic exercise lessens fatigue and improves performance for a number of chronic conditions associated with a high prevalence of fatigue, including CHF, COPD, arthritis, and cancer. Continuous positive airway pressure is an effective treatment for obstructive sleep apnea. Psychostimulants such as methylphenidate have shown inconsistent results in randomized trials of treatment of cancer-related fatigue.

B. Chronic Fatigue Syndrome

A variety of agents and modalities have been tried for the treatment of chronic fatigue syndrome. Acyclovir, intravenous immunoglobulin, nystatin, and low-dose hydrocortisone/fludrocortisone do not improve symptoms. There is a greater prevalence of past and current psychiatric diagnoses in patients with this syndrome. Affective disorders are especially common, but fluoxetine alone, 20 mg daily, is not beneficial. Patients with chronic fatigue syndrome have benefited from a comprehensive multidisciplinary intervention, including optimal medical management, treating any ongoing affective or anxiety disorder pharmacologically, and implementing a comprehensive cognitive-behavioral treatment program. Cognitive-behavioral therapy, a form of nonpharmacologic treatment emphasizing self-help and aiming to change perceptions and behaviors that may perpetuate symptoms and disability, is helpful. Although few patients are cured, the treatment effect is substantial. Response to cognitive-behavioral therapy is not predictable on the basis of severity or duration of chronic fatigue syndrome, although patients with low interest in psychotherapy rarely benefit. Graded exercise has also been shown to improve functional work capacity and physical function. At present, intensive individual cognitive-behavioral therapy administered by a skilled therapist and graded exercise are the treatments of choice for patients with chronic fatigue syndrome.

In addition, the clinicians sympathetic listening and explanatory responses can help overcome the patients frustrations and debilitation by this still mysterious illness. All patients should be encouraged to engage in normal activities to the extent possible and should be reassured that full recovery is eventually possible in most cases.
 

Dolphin

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so quantity of info is lacking, but what about quality......how many of those texts actually have accurate info in them? I'm betting probably near zero

if they are all writing about GET/CBT etc, the less published the better (of course I'd love to see quality AND quantity)
Good point, Tammie.

Here is some info from the paper:


I'd be particularly worried about psychiatric textbooks in which they feature a bit:
 

Tammie

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well, I just skimmed the actual text and looked thru the charts, and am extremely exhausted and foggy, so I might have missed somethign, but from what i read.....UGH!
 

Hope123

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Haven't read the paper yet but my concerns would be around not discussing harm of GET and also the prognosis of CFS (which are still written in such a way in many texts that the majority of us will recover within a few months-years).

Also, gracenote's looking in online texts make a whole lot more sense than paper texts. Today's docs, even the older ones, use online sources much more than paper. Also, the main places they should look are things like UpToDate (which is probably the most used/ trusted online resource by docs) and the American Board of Internal Medicine board exam reviews (which docs are required to take every few years). I'll run it by Dr. Jason at some point.
 

Dolphin

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Haven't read the paper yet but my concerns would be around not discussing harm of GET and also the prognosis of CFS (which are still written in such a way in many texts that the majority of us will recover within a few months-years).

Also, gracenote's looking in online texts make a whole lot more sense than paper texts. Today's docs, even the older ones, use online sources much more than paper. Also, the main places they should look are things like UpToDate (which is probably the most used/ trusted online resource by docs) and the American Board of Internal Medicine board exam reviews (which docs are required to take every few years). I'll run it by Dr. Jason at some point.
Good points.

I would have liked to have seen pacing mentioned even if it was to point out that no texts mentioned it. Similarly "energy envelope" techniques.