Search

Background. Comprehensive studies of mortality among patients with chronic fatigue (CF) and chronic fatigue syndrome (CFS) have not been published, but several sources suggest that CFS is associated with an elevated risk for suicide. Method. Data on 1201 chronically fatigued patients followed in a university-affiliated tertiary-care clinic for up to 14 years were submitted to the Center for Disease Control and Prevention (CDC) National Death Index (NDI) to evaluate all-cause and suicide-caused death rates against standardized mortality rates (SMRs). We used Life Table Analysis to examine the influence of sex and diagnoses of CFS and depression. Results. All-cause mortality in chronically fatigued patients was no higher than expected, but suicide-caused death rates were more than eight times higher than in the US general population. The significant elevation in the SMR of suicide was restricted to those who did not meet criteria for CFS [SMRCF=14.2, 95% confidence interval (CI) 5.7-29.3 versus SMRCFS=3.6, 95% CI 0.4-12.9]. Among chronically fatigued patients who did not meet CFS criteria, those with a lifetime history of major depression (MD) had higher suicide-caused death rates than among their non-depressed counterparts (SMRMD=19.1, 95% CI 7.0-41.5 versus SMRNMD=5.6, 95% CI 0.1-31.4), although the difference was not significant. Conclusions. CFS does not appear to be associated with increased all-cause mortality or suicide rates. Clinicians, however, should carefully evaluate patients with CF for depression and suicidality. [ABSTRACT FROM AUTHOR]

Background. Empirical findings suggest that psychiatric illness is associated with cardiovascular disease (CVD). The purpose of this study was to compare the strength of the association of lifetime post-traumatic stress disorder (PTSD) and lifetime major depression on CVD among Northern Plains American Indians.Method. A total of 1414 participants aged 18-57 years completed a structured interview that assessed psychiatric diagnoses, alcohol abuse/dependence, self-reported CVD, and traditional CVD risk factors including age, sex, education, diabetes, high blood pressure, and smoking. Logistic regression analyses compared the odds ratios of CVD in participants with and without diagnosed PTSD or major depression.Results. The rates of lifetime PTSD and major depression were 15% and 8% respectively. CVD was more commonly reported by participants with PTSD than by those without PTSD (12% v. 5%, p[less-than-or-eq, slant]0.01). Likewise, more participants with major depression reported CVD than did their non-depressed counterparts (14% v. 6%, p[less-than-or-eq, slant]0·05). PTSD was significantly associated with CVD even after controlling for traditional CVD risk factors and major depression (odds ratio 2.0, confidence interval 1.1-3.8). In contrast, the association of major depression with CVD was not significant after accounting for both traditional risk factors and PTSD.Conclusions. Rates of PTSD are high in American Indian communities. Rising CVD rates in this population may be better understood if PTSD is considered along with other traditional risk factors. Future research should examine the association and mechanisms of PTSD and CVD prospectively. Such data could lead to more effective CVD prevention efforts for American Indians. [ABSTRACT FROM AUTHOR]

Little is known about prevention among elderly or urban American Indian/Alaska Native (AI/AN) populations. We reviewed the medical records of 550 older urban AI/AN primary care patients to evaluate how frequently preventive measures were received. Adherence to guidelines was examined by a culturally appropriate (> or =50 years) and standard age threshold (> or =65 years), and by performance of preventive measures at any time ("ever") and in the past year. Lifetime performance was inadequate for the many measures, including mammograms (56%), fecal occult blood testing (37%), audiometry (33%), visual acuity testing (50%), smoking cessation counseling (50%), and pneumococcal (22%) and influenza (49%) vaccinations. Performance of the measures was less frequent in the prior year, but did not differ by age threshold. Predictors of adherence included female gender, having insurance, and having more health problems and medications. Nonadherence infrequently resulted from patients' failure to comply with recommendations. We conclude that use of most preventive services among elderly urban AI/ANs is suboptimal and should be improved. [ABSTRACT FROM AUTHOR]

Objectives: Chronically fatiguing illness, defined as fatigue for at least 6 months, has been associated with various physical health conditions. Our objective was to determine whether there is a significant relationship between chronically fatiguing illness and 10 clinical conditions that frequently appear to be associated with fatigue, adjusting for the potentially confounding effects of psychiatric illness.Design: A co-twin control study controlling for genetic and many environmental factors by comparing chronically fatigued twins with their nonfatigued co-twins.Setting: A nationally distributed volunteer twin registry.Participants: The study included 127 twin pairs in which one member of the pair experienced fatigue of at least 6 months' duration and the co-twin was healthy and denied chronic fatigue. Fatigued twins were classified into 3 levels using increasingly stringent diagnostic criteria.Measurements and Main Results: Twins reported on a history of fibromyalgia, irritable bowel syndrome, multiple chemical sensitivities, temporomandibular disorder, interstitial cystitis, postconcussion syndrome, tension headache, chronic low back pain, chronic pelvic pain (women), and chronic nonbacterial prostatitis (men). The prevalence of these comorbid clinical conditions was significantly higher in the fatigued twins compared to their nonfatigued co-twins. Most notably, compared to their nonfatigued co-twins, the chronically fatigued twins had higher rates of fibromyalgia (> 70% vs < 10%) and irritable bowel syndrome (> 50% vs < 5%). The strongest associations were observed between chronic fatigue and fibromyalgia (odds ratios > 20), irritable bowel syndrome, chronic pelvic pain, multiple chemical sensitivities, and temporomandibular disorder (all with odds ratios > or = 4). Regression analysis suggested that the number of comorbid clinical conditions associated with chronic fatigue could not be attributed solely to psychiatric illness.Conclusions: Chronically fatiguing illnesses were associated with high rates of many other clinical conditions. Thus, patients with chronic fatigue may present a complex clinical picture that poses diagnostic and management challenges. Nonetheless, clinicians should assess such patients for the presence of comorbid clinical conditions. Future research should provide a better understanding of the temporal relationship of the onset of fatigue and these conditions, and develop strategies for early intervention. [ABSTRACT FROM AUTHOR]

Objective: The predictive power of partners' responses to illness behavior for illness outcomes was investigated among couples in which one person had chronic fatigue syndrome (CFS).Methods: One hundred nineteen participants who met case-definition criteria for CFS and were living with a significant other (SO) completed self-report measures of relationship satisfaction, responses of their SO to fatigue symptoms, and outcome measures of fatigue and functional status.Results: The results indicated that more frequent solicitous SO responses to illness behavior were predictive of greater fatigue-related severity and bodily pain. Solicitous SO responses to fatigue behavior were particularly influential in the context of a satisfactory relationship. In highly satisfactory relationships, solicitous SO responses were associated with significantly greater fatigue severity and fatigue-related disability than in relationships characterized by low or average satisfaction.Conclusions: Solicitous SO responses to CFS-related symptoms are associated with poorer patient outcomes, especially in the context of a satisfactory intimate relationship. Because of the cross-sectional nature of the study, the direction of effects cannot be interpreted unambiguously. SOs may be inadvertently positively reinforcing illness-related behavior: Solicitous partners may help the patient more with tasks of daily living, thereby decreasing the patient's activity level, which may lead to deconditioning and disability. Alternatively, patients with more severe symptoms and disability may present more opportunities for concerned SO responses, which again may be heightened in the context of a caring, satisfactory relationship. In either case, the results suggest that additional research on the role of solicitous SO responses is warranted. [ABSTRACT FROM AUTHOR]

PURPOSE: The Association of American Indian Physicians, the only national organization of its kind, conducted a series of focus groups to gather input from tribal leaders, Indian health professionals, and American Indian community members to guide the development of culturally appropriate diabetes education materials for the National Diabetes Education Program. METHODS: During the focus groups, participants shared their experiences with and recommendations for a variety of diabetes education materials. RESULTS: Overall, 95% of participants expressed a strong preference for diabetes education materials relevant to their specific tribe or culture. CONCLUSIONS: Recommendations from these focus groups were used to develop a national diabetes education campaign for American Indian communities. [ABSTRACT FROM AUTHOR]

Purpose: Chronic fatigue (CF) is a common complaint in ambulatory settings. Chronic fatigue syndrome (CFS) is characterized by profound fatigue associated with other symptoms that is rarely reported in racial/ethnic minorities. Our objectives were to determine if differences exist between Caucasian and minority patients presenting with CF, particularly in the frequency meeting criteria for CFS. Patients: 690 patients with CF seen in a university-based referral clinic. Design/Methods: Demographic, historical, physical examination, laboratory, and psychosocial information was prospectively collected and compared. Psychosocial assessment consisted of a structured psychiatric interview, the Medical Outcomes Study Short-Form Health Survey to assess functional status, the General Health Questionnaire to ascertain psychological distress, and measures of health locus of control, illness attribution, social support, and coping. Results: With the exception of less social support from friends, no significant race/ethnicity-related differences were identified. Minority patients tended less commonly to report a moderate level of fatigue, and to have poorer social function, less social support from families, and lower rates of lifetime major depression and alcohol abuse. Conclusions: Demographic, clinical, and psychosocial factors do not distinguish Caucasian from minority CF patients. Help-seeking behaviors, access to care, and the significance attributed to the central complaints should be examined as potentially competing explanations for these findings. [ABSTRACT FROM AUTHOR]

Presents an update on chronic fatigue syndrome (CFS) which is characterized by debilitating fatigue and associated symptoms. Differential diagnosis of chronic fatigue; Differences between CFS and major depression; Evidence of chronic immune activation; Prevalence of CFS.

Objective: To assess the comprehensibility of hepatitis B translations for Cambodian refugees, to identify Cambodian illnesses that include the symptoms of hepatitis, and to combine these observations with critical theoretical perspectives of language to reflect on the challenges of medical translations generally.Design: Open-ended, semistructured interviews, and participant-observation of a refugee community in Seattle, Washington.Setting: Homes of Cambodian residents of inner-city neighborhoods.Participants: Thirty-four adult Cambodian refugees who had each been educated about hepatitis B through public health outreach.Results: Medical interpreters translated hepatitis B as rauk tlaam, literally "liver disease." Unfortunately, while everyone knew of the liver (tlaam), rauk tlaam was a meaningless term to 28 (82%) of 34 respondents and conveyed none of the chronicity and communicability intended by refugee health workers for 34 (100%) of the respondents. In contrast, all respondents knew illnesses named after symptom complexes that include the symptoms of acute and chronic hepatitis, but do not refer to diseased organs. The Cambodian words chosen to translate hepatitis B reflect the medical thinking and medical authority that can unintentionally overwhelm attempts at meaningful communication with non-English-speaking patients.Conclusions: To improve comprehension of hepatitis B translations for the Khmer, translators must choose between medical terminology focused on the liver and Khmer terminology which identifies recognizable experiences, but represents important Khmer health concepts. A critical linguistic view of this situation suggests that for these translations to be meaningful clinicians and health educators must first analyze and then monitor the contextual significance of medical language. In cross-cultural settings, this means a partnership with medical interpreters to pay close attention to the experience of illness and social context of the translation. [ABSTRACT FROM AUTHOR]

Objective: To identify important determinants of noncompliance among Cambodian refugees.Design: Open-ended interviews.Setting: University-affiliated ambulatory care clinic in an inner-city hospital.Participants: Thirty adult Cambodian refugees (15 men and 15 women) who were regular utilizers of a refugee clinic.Measurements and Main Results: Sixty-seven percent of the participants described being noncompliant with at least one of their medications. Four common causes of noncompliance were identified: 1) misunderstanding the intent of the medication; 2) side effects; 3) concern about the effect of medication on "internal strength"; and 4) Cambodian ideas about pharmacokinetics.Conclusions: Noncompliance was commonly reported by the Cambodian respondents. Noncompliance was both intentional and unintentional; the unintended noncompliance derived from patients' attempting to comply with therapy according to Cambodian ideas about the body and Western medication. This article suggests clinical approaches to enhance compliance with prescribed regimens among recent Cambodian immigrants and refugees. [ABSTRACT FROM AUTHOR]

Objective: To determine whether there are differences between men and women patients who have chronic fatigue syndrome (CFS) and, if so, to ascertain whether a gender-related pattern exists.Design: A descriptive study of demographic, clinical, and psychosocial measures, the results of which were prospectively collected for patients who had CFS.Setting: A university-based referral clinic devoted to the evaluation and management of chronic fatigue.Patients: 348 CFS patients who had undergone complete medical evaluations.Measures: Clinical variables included symptoms, physical examination findings, and laboratory results. Psychosocial assessment consisted of a structured psychiatric interview, the Medical Outcomes Study Short-form General Health Survey to assess functional status, the General Health Questionnaire to ascertain psychological distress, the Multidimensional Health Locus of Control, and measures of attribution, social support, and coping.Main Results: Overall, few gender-related differences were identified. Women had a higher frequency of tender or enlarged lymph nodes (60% versus 33%, p < or = 0.01) and fibromyalgia (36% versus 12%, p < or = 0.001) and lower scores on the physical functioning subscale of the Medical Outcomes Study Short-form General Health Survey (37.6 versus 52.2, p < 0.01); men more often had pharyngeal inflammation (42% versus 22%, p < or = 0.001) and reported a higher lifetime prevalence of alcoholism (20% versus 9%, p < or = 0.01).Conclusions: In general, demographic, clinical, and psychosocial factors do not distinguish men from women CFS patients. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of depressive symptoms among Vietnamese refugees who have lived in the United States for at least two months.Design: A prospective and descriptive study using the Vietnamese Depression Scale (VDS). Scores of > or = 13 on the VDS were considered indicative of depression.Setting: Ten public health clinics in four states.Patients/participants: Four hundred seventy-six consecutive adult Vietnamese refugees presenting for primary care.Interventions: The VDS, an 18-item culture-specific self-report measure, was used to screen for depressive symptoms.Measurements and Main Results: Twenty percent of these patients had scores of 13 or above. Although being female; being older; being divorced, separated, or widowed; and being poorly educated were significant univariate risk factors for screening positive, only the latter two were significant in a multivariate model. Physical complaints were common and induced considerable anxiety about health status, but psychological and emotional symptoms were even more prevalent. Patients scoring 13 or higher had a higher rate of endorsement for every item in the scale than did those scoring lower than 13.Conclusions: This study substantiates the feasibility and importance of screening for depressive symptoms among Vietnamese refugees, particularly in primary care settings where they are most likely to seek care for both medical and psychological problems. [ABSTRACT FROM AUTHOR]

Objectives: To identify psychiatric differences between patients with chronic fatigue and those with rheumatoid arthritis and to investigate whether patients meeting Centers for Disease Control (CDC) criteria for chronic fatigue syndrome (CFS) can be differentiated from patients with chronic fatigue on measures of disability and psychosocial distress.Design: Cross-sectional study comparing 98 patients with chronic fatigue with 31 patients with rheumatoid arthritis on structured psychiatric interviews and patient questionnaires. Nineteen patients meeting CDC criteria for CFS were compared with 79 patients with chronic fatigue not meeting CDC criteria on questionnaires measuring disability and psychosocial distress.Setting: Consecutive patients with chronic fatigue were selected from a chronic fatigue clinic at the University of Washington, and 31 consecutive patients with rheumatoid arthritis were sampled from a private rheumatology practice.Main Results: Patients with chronic fatigue had a significantly higher prevalence of lifetime major depression and somatization disorder than did patients with rheumatoid arthritis. Patients with chronic fatigue also had a significantly higher prevalence of current and lifetime psychiatric diagnoses. Only 19 of 98 patients with chronic fatigue met CDC criteria for CFS. Patients meeting CDC criteria for CFS could not be differentiated from the larger group of patients with chronic fatigue on any study variable.Conclusions: Patients with chronic fatigue have a significantly higher burden of psychiatric illness than do patients with rheumatoid arthritis. The psychiatric illness preceded the development of chronic fatigue in over half the patients. Centers for Disease Control criteria for CFS did not select a subset of chronic fatigue patients who could be differentiated on disability or psychosocial parameters from patients with chronic fatigue who did not meet CDC criteria. [ABSTRACT FROM AUTHOR]

Some patients' beliefs about the causes and cures of illness are at odds with your Western biomedical training. To treat them successfully, you need to understand their health perceptions, behaviors, and expectations. [ABSTRACT FROM AUTHOR]

Choice of an interpreter: Ideally, use interpreters who are familiar with the patient's culture and with biomedicine and who are trained in encounters with patients and cross-cultural communication. Bilingual nursing or office staff with awareness of cultural issues and good communication skills may be appropriate, but interpretation should not be tacked on to other duties. Generally avoid using family members -- especially children -- friends, or strangers from the waiting room as interpreters for reasons of competence and confidentiality. [ABSTRACT FROM AUTHOR]

In order to make meaningful scholarly contributions, clinician-educators need protected time. Forty-one clinician-educators at the University of Washington recorded their work activities in 30-minute intervals for 2 weeks. The average work week was 58.7 hours (SD = 13.8). The time devoted to scholarship, 7.6 hours (13%), was significantly less than the 20% designated for scholarship in the clinician-educator job description (p < .001); 42% of scholarly work occurred outside the regular work week. At a time when many schools rely on clinician-educators to sustain their clinical and teaching missions, schools should ensure that faculty have adequate time and resources to meet scholarly expectations for promotion. [ABSTRACT FROM AUTHOR]

A workshop was held 18 to 19 March 1991 at the National Institutes of Health to address critical issues in research concerning the chronic fatigue syndrome (CFS). Case definition, confounding diagnoses, and medical outcome assessment by laboratory and other means were considered from the perspectives of key medical specialties involved in CFS research. It was recommended that published Centers for Disease Control (CDC) case-definition criteria be modified to exclude fewer patients from analysis because of a history of psychiatric disorder. Specific recommendations were made concerning the inclusion or exclusion of other major confounding diagnoses, and a standard panel of laboratory tests was specified for initial patient evaluation. The workshop emphasized the importance of recognizing other conditions that could explain the patient's symptoms and that may be treatable. It was viewed as essential for the investigator to screen for psychiatric disorder using a combination of self-report instruments followed by at least one structured interview to identify patients who should be excluded from studies or considered as a separate subgroup in data analysis. Because CFS is not a homogeneous abnormality and because there is no single pathogenic mechanism, research progress may depend upon delineation of these and other patient subgroups for separate data analysis. Despite preliminary data, no physical finding or laboratory test was deemed confirmatory of the diagnosis of CFS. For assessment of clinical status, investigators must rely on the use of standardized instruments for patient self-reporting of fatigue, mood disturbance, functional status, sleep disorder, global well-being, and pain. Further research is needed to develop better instruments for quantifying these domains in patients with CFS. [ABSTRACT FROM AUTHOR]

Objective: To conduct neurologic, immunologic, and virologic studies in patients with a chronic debilitating illness of acute onset.Design: Cohort study with comparison to matched, healthy control subjects.Patients: We studied 259 patients who sought care in one medical practice; 29% of the patients were regularly bedridden or shut-in.Main Outcome Measures: Detailed medical history, physical examination, conventional hematologic and chemistry testing, magnetic resonance imaging (MRI) studies, lymphocyte phenotyping studies, and assays for active infection of patients' lymphocytes with human herpesvirus type 6 (HHV-6).Main Results: Patients had a higher mean (+/- SD) CD4/CD8 T-cell ratio than matched healthy controls (3.16 +/- 1.5 compared with 2.3 +/- 1.0, respectively; P less than 0.003). Magnetic resonance scans of the brain showed punctate, subcortical areas of high signal intensity consistent with edema or demyelination in 78% of patients (95% CI, 72% to 86%) and in 21% of controls (CI, 11% to 36%) (P less than 10(-9)). Primary cell culture of lymphocytes showed active replication of HHV-6 in 79 of 113 patients (70%; CI, 61% to 78%) and in 8 of 40 controls (20%; CI, 9% to 36%) (P less than 10(-8], a finding confirmed by assays using monoclonal antibodies specific for HHV-6 proteins and by polymerase chain reaction assays specific for HHV-6 DNA.Conclusions: Neurologic symptoms, MRI findings, and lymphocyte phenotyping studies suggest that the patients may have been experiencing a chronic, immunologically mediated inflammatory process of the central nervous system. The active replication of HHV-6 most likely represents reactivation of latent infection, perhaps due to immunologic dysfunction. Our study did not directly address whether HHV-6, a lymphotropic and gliotropic virus, plays a role in producing the symptoms or the immunologic and neurologic dysfunction seen in this illness. Whether the findings in our patients, who came from a relatively small geographic area, will be generalizable to other patients with a similar syndrome remains to be seen. [ABSTRACT FROM AUTHOR]

Discusses the treatment response and residual-disease monitoring in initial and relapsed childhood acute lymphoblastic leukemia (ALL). Significance of detection of minimal residual disease after induction remission; Methods for detection of the disease; Characteristics of the genetic rearrangement in childhood ALL.

To ascertain the extent of, and risk factors for, physical abuse among older urban American Indian/Alaska Natives (AI/ANs), we conducted a chart review of 550 urban AI/AN primary care patients >/=50 years old seen during 1 year. Mistreatment was documented in 10%. A logistic regression found younger age (P <.001), female gender (P <.001), current depression (P <.001), and dependence on others for food (P <.05) to be significant correlates of physical abuse. In only 31% of instances of definite abuse were the authorities notified. We conclude that providers should be alert to the possibility of physical mistreatment among older urban AI/ANs. Improvements in detection and management are sorely needed. [ABSTRACT FROM AUTHOR]

To determine how often housestaff notified primary care providers (PCPs) of admissions, whether notification prompted a visit, and whether PCP input impacted care, 210 medical inpatients were asked about their PCPs, and at discharge, housestaff completed a questionnaire on the patient's PCP, and whether he or she was contacted, came to the hospital, and influenced care. Of 105 patients with a PCP, 74 were contacted and 26 visited their patients. The PCPs spoken with personally more often made hospital visits than those contacted only by message (p < 0.0001). PCP input frequently contributed to patient care by providing continuity, clarifying history/diagnosis, managing chronic problems, and elucidating psychosocial/cultural factors. Having a PCP did not influence length of stay or readmission rates. [ABSTRACT FROM AUTHOR]