Jump to content

Myalgic encephalomyelitis/chronic fatigue syndrome

From Wikipedia, the free encyclopedia

This is an old revision of this page, as edited by Sciencewatcher (talk | contribs) at 16:50, 29 December 2023 (→Neurological: more correctly match source (neuroinflammation != inflammation)). The present address (URL) is a permanent link to this revision, which may differ significantly from the current revision.

Not to be confused with chronic fatigue, which is the symptom experienced in many chronic illnesses; including idiopathic chronic fatigue and fibromyalgia.

Chronic fatigue syndrome
Other namesMyalgic encephalomyelitis/ chronic fatigue syndrome (ME/CFS),[1] myalgic encephalomyelitis (ME), post-viral fatigue syndrome (PVFS), chronic fatigue immune dysfunction syndrome (CFIDS), systemic exertion intolerance disease (SEID), others[2]: 20 
Chart of the symptoms of ME/CFS according to various definitions
SpecialtyRheumatology, rehabilitation medicine, endocrinology, infectious disease, neurology, immunology, internal medicine, paediatrics, other specialists in ME/CFS[3]
SymptomsWorsening of symptoms with activity, long-term fatigue, others[1]
Usual onsetPeaks at 10-19 and 30-39 years old[4]
DurationLong-term[5]
CausesUnknown[1]
Risk factorsFemale sex, virus and bacterial infections, blood relatives with the illness, major injury, bodily response to psychological stress and others[6][7]: 1–2 
Diagnostic methodBased on symptoms[1]
TreatmentSymptomatic[8][9]
PrevalenceAbout 0.68 to 1% globally[10][11]

Chronic fatigue syndrome (CFS), also called myalgic encephalomyelitis (ME) or ME/CFS, is a complex and debilitating long-term medical condition. Core symptoms are lengthy flare-ups of the illness following ordinary minor physical or mental activity, known as post-exertional malaise (PEM); greatly diminished capacity to do tasks that were routine before the illness; and sleep disturbances.[12][13] Orthostatic intolerance (difficulty sitting and standing upright) or memory and attention problems may also be required for diagnosis. Frequently, other symptoms occur involving numerous body systems, and chronic pain is very common.[13] The often incapacitating fatigue in ME/CFS is different from that caused by normal strenuous exertion and is not significantly relieved by rest.[13]

The root cause(s) of the disease are unknown and the mechanisms are not fully understood.[14] ME/CFS often starts after a flu-like infection, for instance after infectious mono.[15][6] In some people, physical trauma or psychological stress may also act as a trigger.[16]: 10  A genetic component is suspected, as ME/CFS can run in families.[17] ME/CFS is associated with changes in the nervous and immune system, energy metabolism and hormone production.[14][18] Diagnosis is based on symptoms because no confirmed diagnostic test is available.[19]

People with ME/CFS may recover or improve over time, but some will become severely affected and disabled for an extended period.[20] No therapies or medications are approved to treat the cause of the illness; treatment is aimed at alleviation of symptoms.[8][21] Pacing and energy envelope (activity management) can help to prevent flare-ups.[8] Limited evidence suggests that counseling,[22] pacing,[21] and the use of rintatolimod help improve functional abilities in some.

About 1% of primary-care patients have ME/CFS; estimates vary widely because studies have used different definitions.[11][19][10] About a quarter of people with ME/CFS are severely affected and unable to leave their bed or house.[16]: 3  ME/CFS occurs 1.5 to 2 times as often in women as in men.[11] It most commonly affects adults between 40 and 60 years old,[23] but can occur at other ages, including childhood.[24] In children, ME/CFS is a major cause of school absence.[2]: 183  ME/CFS significantly reduces health, happiness, productivity, and can also lead to loneliness and alienation.[25]

People with ME/CFS often face stigma in healthcare settings, and doctors may have trouble managing an illness that lacks a clear cause or treatment.[2]: 30 [26] Historical research funding for ME/CFS has been far below that of comparable diseases.[27] There is controversy over many aspects of the disorder, including the name, cause and potential treatments.[28]

Classification

ME/CFS has been classified as neurological disease by the World Health Organization (WHO) since 1969, initially under the name benign myalgic encephalomyeltis.[29] Even though the cause of the illness is unknown, symptoms point to a central role of the nervous system.[30]

In the WHO's most recent classification, ICD-11, both chronic fatigue syndrome and myalgic encephalomyelitis are listed under the term post-viral fatigue syndrome. They are classified as other disorders of the nervous system.[31] In the ICD-10, only (benign) ME was listed, and there was no mention of CFS. Clinicians often used fatigue and malaise, or fatigue syndrome for people with CFS.[32]

Signs and symptoms

The United States Centers for Disease Control and Prevention (CDC) recommends these criteria for diagnosis:[13]

  1. Greatly lowered ability to do activities that were usual before the illness. This drop in activity level occurs along with fatigue and must last six months or longer.
  2. Worsening of symptoms after physical or mental activity that would not have caused a problem before the illness. The amount of activity that might aggravate the illness is difficult for a person to predict, and the decline often presents 12 to 48 hours after the activity.[33] The 'relapse', or 'crash', may last days, weeks or longer. This is known as post-exertional malaise (PEM).
  3. Sleep problems; people may still feel weary after full nights of sleep, or may struggle to stay awake, fall asleep or stay asleep.

Additionally, one of the following symptoms must be present:[13]

  • Problems with thinking and memory (cognitive dysfunction, sometimes described as "brain fog")
  • While standing or sitting upright; lightheadedness, dizziness, weakness, fainting or vision changes may occur (orthostatic intolerance)

Other common symptoms

Many, but not all people with ME/CFS report:[13]

Increased sensitivity to sensory stimuli and pain have also been observed in CFS.[20][34]

Onset

The onset of ME/CFS may be gradual or sudden.[2] When it begins suddenly, it often follows an episode of infectious-like symptoms or a known infection, and between 25% and 80% report an infectious-like onset.[2]: 158 [35] When gradual, the illness may begin over the course of months or years with no apparent trigger.[36] It's also frequent for the onset of ME/CFS to involve multiple triggering events that begin with minor symptoms and culminate in a final trigger leading to a noticeable onset.[37] Studies disagree as whether sudden or gradual onset is more common.[2]: 158 : 181  ME/CFS may also occur after physical trauma such as a car accident or surgery.[36]

Physical functioning

Results of a study on quality of life of people with ME/CFS, showing it to be lower than in 20 other chronic conditions

ME/CFS often causes significant disability, but the degree can vary greatly.[1][36] Some people with mild ME/CFS may lead relatively normal lives with vigilant energy management, while moderately affected patients may be unable to work or spend much time upright. People with severe ME/CFS are generally housebound or bedbound, and may be unable to care for themselves.[36] About a quarter of people with ME/CFS fall in the severe category.[16]: 3 

The majority of people with ME/CFS have significant difficulty engaging in work, school, and family activities for extended periods of time.[13][36] An estimated 75% are unable to work because of their illness, and about 25% are housebound or bedridden for long periods, often decades.[2]: 32 [38][39] In one review on employment status, more than half of CFS patients were on disability benefits or temporary sick leave, and less than a fifth worked full-time.[40] In children, ME/CFS is a major cause of school absence.[2]: 183  Many people with CFS also experience strongly disabling chronic pain.[41]

Symptoms can fluctuate over time, making the condition difficult to manage. Persons who feel better for a period may overextend their activities, triggering post-exertional malaise and a worsening of symptoms.[33] Severity may also change over time, with periods of worsening, improvement or remission sometimes occurring.[36]

People with CFS have decreased quality of life according to the SF-36 questionnaire, especially in the domains of vitality, physical functioning, general health, physical role, and social functioning. However, their scores in the "role emotional" and mental health domains were not substantially lower than healthy controls.[42] A 2015 study found that people with ME/CFS had lower health-related quality of life than 20 other chronic conditions, including multiple sclerosis, kidney failure, and lung cancer.[43]

Cognitive functioning

Cognitive dysfunction is one of the most disabling aspects of CFS due to its negative impact on occupational and social functioning. 50–80% of people with CFS are estimated to have serious problems with cognition.[44] Cognitive symptoms are mainly due to deficits in attention, memory, and reaction time. Measured cognitive abilities are found to be below projected normal values and likely to affect day-to-day activities, causing increases in common mistakes, forgetting scheduled tasks, or having difficulty responding when spoken to.[45]

Simple and complex information-processing speed and functions entailing working memory over long time periods are moderately to extensively impaired. These deficits are generally consistent with the patient's perceptions. Perceptual abilities, motor speed, language, reasoning, and intelligence do not appear to be significantly altered. Patients who report poorer health status tend to also report more severe cognitive trouble, and better physical functioning is associated with less visuoperceptual difficulty and fewer language-processing complaints.[45]: 24 

Inconsistencies of subjective and observed values of cognitive dysfunction reported across multiple studies are likely caused by a number of factors. Differences of research participants' cognitive abilities pre- and post-illness onset are naturally variable and are difficult to measure because of a lack of specialized analytical tools that can consistently quantify the specific cognitive difficulties in CFS.[45]

Cause

The cause of ME/CFS is unknown.[42][15] Both genetic and environmental factors are believed to contribute, but the genetic component is unlikely to be a single gene.[42] Problems with the nervous and immune systems, and energy metabolism, may be factors.[15] ME/CFS is a biological disease, not a psychiatric or psychological condition,[46][42] and is not caused by deconditioning.[42][47]

Because the illness often follows a known or apparent viral illness, various infectious agents have been proposed, but a single cause has not been found.[48][2][42] For instance, ME/CFS may start after mononucleosis, a H1N1 influenza infection, a varicella zoster virus infection (the virus that causes chickenpox), or SARS-CoV-1[49] and SARS-CoV-2.[50]

Risk factors

All ages, ethnic groups, and income levels are susceptible to the illness. The CDC states that while Caucasians may be diagnosed more frequently than other races in America,[38] the illness is at least as prevalent among African Americans and Hispanics.[23] A 2009 meta-analysis found that Asian Americans have a lower risk of CFS than White Americans, while Native Americans have a higher (probably a much higher) risk and African Americans probably have a higher risk. The review acknowledged that studies and data were limited.[51]

More women than men get ME/CFS.[38] A large 2020 meta-analysis estimated that between 1.5 and 2.0 times more cases are women. The review noted that different case definitions and diagnostic methods within datasets yielded a wide range of prevalence rates.[11] The CDC estimates ME/CFS occurs up to four times more often in women than in men.[23] The illness can occur at any age, but has the highest prevalence in people aged 40 to 60.[23] ME/CFS is less prevalent among children and adolescents than among adults.[24]

People with affected relatives appear to be more likely to get ME/CFS, implying the existence of genetic risk factors.[17] People with a family history of neurological or autoimmune diseases are also at increased risk.[37] Results of genetic studies have been largely contradictory or unreplicated. One study found an association with mildly deleterious mitochondrial DNA variants, and another found an association with certan variants of human leukocyte antigen genes.[17]

Viral and other infections

Main article: Post-acute infection syndrome

Post-viral fatigue syndrome (PVFS) or post-viral syndrome describes a type of chronic fatigue syndrome that occurs following a viral infection.[35] Viral infection is a significant risk factor for ME/CFS. Different types of viral infection can lead to ME/CFS, including airway infections, bronchitis, gastroenteritis, or an acute "flu-like illness".[16]: 226  One review found higher Epstein–Barr virus (EBV) antibody activity in people with ME/CFS, and that a subset were likely to have increased EBV activity compared to controls.[52] Of people infected with EBV, around 8% to 15% develop ME/CFS, depending on criteria.[16]: 226  Between 15% to 50% of people with long COVID also meet the diagnostic criteria for ME/CFS.[16]: 228 

A systematic review found that fatigue severity was the main predictor of prognosis in CFS, and did not identify psychological factors linked to prognosis.[53] Another review found that risk factors for developing post-viral fatigue or CFS after mononucleosis, dengue fever, or Q-fever included longer bed-rest during the illness, poorer pre-illness physical fitness, attributing symptoms to physical illness, belief that a long recovery time is needed, as well as pre-infection distress and fatigue.[54] The same review found biological factors such as CD4 and CD8 activation and liver inflammation are predictors of sub-acute fatigue but not CFS.[54]

A study analyzing the relationship between diagnostic labels and prognosis found that people diagnosed with ME had the worst prognosis, and that people with PVFS had the best. According to a review, it is unclear whether this was because people labeled with ME had a more severe or persistent illness, or because being labelled with ME adversely affects prognosis.[55] The National Academy of Medicine report says it is a misconception that diagnosing ME/CFS worsens prognosis, and that accurate diagnosis is key to appropriate management.[2]: 222 : 235 

Pathophysiology

ME/CFS is associated with changes in several areas, including the nervous, immune, and endocrine systems.[14][18] Reported neurological differences include altered brain structure and metabolism, and autonomic nervous system dysfunction.[18] Observed immunological changes include decreased natural killer cell activity, increased cytokines.[14] Endocrine differences, such as modestly low cortisol and HPA axis dysregulation, have been noted as well.[14] Impaired energy production and the possibility of autoimmunity are other areas of interest.[15]

Neurological

Brain imaging, comparing adolescents with CFS and healthy controls showing abnormal network activity in regions of the brain.
Brain imaging, comparing adolescents with CFS and healthy controls showing abnormal network activity in regions of the brain

A range of neurological structural and functional abnormalities is found in people with CFS, including lowered metabolism at the brain stem and reduced blood flow to cortical areas of the brain; these differences are consistent with neurological illness, but not depression or psychological illness.[7]

Neuroinflammation has been proposed as a underlying mechanism of ME/CFS that could explain a large set of symptoms. Multiple lines of evidence suggest neuroinflammatory abnormalities in the cortical and limbic regions of the brain in people with ME/CFS. People with ME/CFS for instance have higher brain lactate and choline levels, which point to neuroinflammation. Two small PET studies of microglia, a type of immune cell in the brain, were contradictory however. Neuroinflammation is a common feature of neurological diseases.[56]

Some neuroimaging studies have observed prefrontal and brainstem hypometabolism; however, sample size was limited.[18] Neuroimaging studies in persons with ME/CFS have identified changes in brain structure and correlations with various symptoms. Results were however not consistent across the neuroimaging brain structure studies.[57][18]

ME/CFS affects sleep. People with ME/CFS experience decreased sleep efficiency, take longer to fall asleep and longer to achieve REM sleep. Changes to non-REM sleep have also been found, together suggesting a role of the autonomic nervous system.[58][59] People with ME/CFS often have an abnormal heart rate response to a tilt table test, in which a patient is moved from a flat to an upright position. This again suggests dysfunction in the autonomic nervous system.[60]

Central sensitization, or increased sensitivity to sensory stimuli such as pain have been observed in CFS. Sensitivity to pain increases after exertion, which is opposite to the normal pattern.[34]

Immunological

Immunological abnormalities are frequently observed in those with CFS. Decreased NK cell activity is found more often in people with CFS and this correlates with severity of symptoms.[6][61] People with CFS have an abnormal response to exercise, including increased production of complement products, increased oxidative stress combined with decreased antioxidant response, and increased interleukin 10, and TLR4, some of which correlates with symptom severity.[62] Increased levels of cytokines have been proposed to account for the decreased ATP production and increased lactate during exercise;[63][64] however, the elevations of cytokine levels are inconsistent in specific cytokine, albeit frequently found.[2][65] Similarities have been drawn between cancer and CFS with regard to abnormal intracellular immunological signaling. Abnormalities observed include hyperactivity of ribonuclease L, a protein activated by IFN, and hyperactivity of NF-κB.[66]

Endocrine

Evidence points to abnormalities in the hypothalamic-pituitary-adrenal axis (HPA axis) in some people with ME/CFS, which may include lower cortisol levels, a decrease in the variation of cortisol levels throughout the day and decreased responsiveness of the HPA axis. This can be considered to be a "HPA axis phenotype" that is also present in some other conditions, including post-traumatic stress disorder and some autoimmune conditions.[67] It is unclear whether or not decreased cortisol levels of the HPA axis plays a primary role as a cause of CFS,[68][69][70] or has a secondary role in the continuation or worsening of symptoms later in the illness.[71] In most healthy adults, the cortisol awakening response shows an increase in cortisol levels averaging 50% in the first half-hour after waking. In people with CFS, this increase apparently is significantly less, but methods of measuring cortisol levels vary, so this is not certain.[72]

Autoimmunity

Autoimmunity has been proposed to be a factor in ME/CFS, but there are only a few relevant findings so far. There is a subset of people with ME with increased B cell activity and autoantibodies, possibly as a result of decreased NK cell regulation or viral mimicry.[73] In 2015, a large German study found 29% of people with ME/CFS had elevated autoantibodies to M3 and M4 muscarinic acetylcholine receptors as well as to ß2 adrenergic receptors.[74][75][76] Problems with these receptors can lead to impaired blood flow.[76]

Energy metabolism

Objective signs of PEM have been found with the 2-day CPET, a test that involves taking VO2max tests on successive days. People with ME/CFS have lower performance and heart rate compared to healthy controls on the first test. On the second test, healthy people's scores stay the same or increase slightly, while people with ME/CFS have a decrease in anaerobic threshold, peak power output, and VO2max. Potential causes include impaired oxygen transport, impaired aerobic metabolism, and mitochondrial dysfunction.[77]

Studies have observed mitochondrial abnormalities in cellular energy production, but recent focus has concentrated on secondary effects that may result in aberrant mitochondrial function because inherent problems with the mitochondria structure or genetics have not been replicated.[78]

Diagnosis

Could You Have ME/CFS? from US Centers for Disease Control

No characteristic laboratory abnormalities are approved to diagnose ME/CFS; while physical abnormalities can be found, no single finding is considered sufficient for diagnosis.[15][79] Blood, urine, and other tests are used to rule out other conditions that could be responsible for the symptoms.[80][81][2] A diagnosis may further include taking a medical history and a mental and physical examination.[80]

Diagnostic tools

The CDC recommends considering the questionnaires and tools described in the 2015 Institute of Medicine report, which include:[82]

  • DePaul Symptom Questionnaire
  • CDC Symptom Inventory for CFS
  • The Chalder Fatigue Scale
  • The Krupp Fatigue Severity Scale
  • Work and Social Adjustment Scale (WSAS)
  • SF-36 / RAND-36
  • Pittsburgh Sleep Quality Index (PSQI)[2]: 270 

A two-day cardiopulmonary exercise test (CPET) is not necessary for diagnosis, although lower readings on the second day may be helpful in supporting a claim for Social Security disability. A two-day CPET cannot be used to rule out chronic fatigue syndrome.[2]: 216 

Definitions

Main article: Clinical descriptions of chronic fatigue syndrome

Many sets of diagnostic criteria for ME/CFS have been proposed. Required symptoms vary. The four most commly cited are post-exertional malaise, fatigue, cognitive impairment, and sleep disruption. Notable definitions include:[32][83]

  • Centers for Disease Control and Prevention (CDC) definition (1994),[84] is also called the Fukuda definition and is a revision of the Holmes or CDC 1988 scoring system.[85] The 1994 criteria require the presence of four or more symptoms beyond fatigue, while the 1988 criteria require six to eight.[86]
  • The 2003 Canadian consensus criteria[87] state: "A patient with ME/CFS will meet the criteria for fatigue, post-exertional malaise and/or fatigue, sleep dysfunction, and pain; have two or more neurological/cognitive manifestations and one or more symptoms from two of the categories of autonomic, neuroendocrine, and immune manifestations; and the illness persists for at least 6 months".
  • The Myalgic Encephalomyelitis International Consensus Criteria (ICC) published in 2011 is based on the Canadian working definition.[88][7] The ICC does not have a six months waiting time for diagnosis. The ICC requires post-exertional neuroimmune exhaustion (PENE) which has similarities with post-exertional malaise, plus at least three neurological symptoms, at least one immune or gastrointestinal or genitourinary symptom, and at least one energy metabolism or ion transportation symptom. Unrefreshing sleep or sleep dysfunction, headaches or other pain, and problems with thinking or memory, and sensory or movement symptoms are all required under the neurological symptoms criterion.[88] Patients with post-exertional neuroimmune exhaustion but only partially meeting the criteria are given the diagnosis of atypical myalgic encephalomyelitis.[88]
  • The 2015 definition by the National Academy of Medicine (then referred to as the "Institute of Medicine") is not a definition of exclusion (differential diagnosis is still required).[2] "Diagnosis requires that the patient have the following three symptoms: 1) A substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities, that persists for more than 6 months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest, and 2) post-exertional malaise 3) Unrefreshing sleep; At least one of the two following manifestations is also required: 1) Cognitive impairment 2) Orthostatic intolerance"[2]

The 2021 UK National Institute for Health and Care Excellence (NICE) guidelines employ a definition of ME/CFS that requires severe fatigue, post-exertional malaise, unrefreshing sleep or sleep disturbance, and cognitive difficulties.[89]

Differential diagnosis

Certain medical conditions have similar symptoms as ME/CFS and should be evaluated before a diagnosis of ME/CFS can be confirmed. While alternative diagnoses are explored, advice can be given on symptom management, to avoid delays in care.[89] Post-exertional malaise often acts as a distinguishing feature of ME/CFS. A diagnosis of ME/CFS is only confirmed after six months of symptoms, to exclude acute medical conditions or problems related to lifestyle, which may resolve within that time frame.[15]

Examples of possible differential diagnoses span a large set of specialties, and depend on patient history.[15] Examples are infectious diseases (such as Epstein–Barr virus, HIV infection, tuberculosis, Lyme disease), neuroendocrine disorder (such as diabetes, hypothyroidism, Addison's disease, adrenal insufficiency), blood disorders (such as anemia) and some cancers. Various rheumatological and auto-immune diseases may also have overlapping symptoms with ME/CFS, such as Sjögren's syndrome, lupus and arthritis. Furthermore, evaluation of psychiatric diseases (such as depression, substance use disorder and anorexia nervosa) and neurological disorders (such as obstructive sleep apnea, narcolepsy, Parkinson's, multiple sclerosis, craniocervical instability) may be warranted.[15][83] Finally, sleep disorders, coeliac disease, connective tissue disorders and side effects of medications may also explain symptoms.[90]

Joint and muscle pain without swelling or inflammation is a feature of ME/CFS, but is more associated with fibromyalgia. Modern definitions of fibromyalgia not only include widespread pain, but also fatigue, sleep disturbances and cognitive issues, making the two syndromes difficult to distinguish.[91]: 13, 26  The two are often co-diagnosed.[92] Ehlers–Danlos syndromes (EDS) may also have similar symptoms.[93]

Like with other chronic illnesses, depression and anxiety co-occur frequently with ME/CFS. Depression may be differentially diagnosed from ME/CFS by feelings of worthlessness, the inability to feel pleasure, loss of interest and/or guilt; and the absence of bodily symptoms such autonomic dysfunction, pain, migraines or post-exertional malaise.[91]: 26 

Management

Main article: Chronic fatigue syndrome treatment

There is no approved drug treatment, therapy or cure for ME/CFS, although some symptoms can be treated or managed.[8][89] Pacing, or managing one's activities to stay within their energy limits, can reduce episodes of post-exertional malaise. Addressing sleep problems with good sleep hygiene, or medication if required, may be beneficial. Chronic pain is common in ME/CFS, and the CDC recommends consulting with a pain management specialist if over-the-counter painkillers are insufficient. The debilitating nature of ME/CFS can cause depression or other psychological problems, which should be treated accordingly. For cognitive impairment, adaptations like organizers and calendars may be helpful. Comorbid conditions are common and should be treated if present.[8]

The CDC recommends a strategy treating the most disabling symptom first, and the NICE guideline specifies the need for shared decision-making between patients and medical teams.[8] NICE recognized that symptoms of severe ME/CFS may be misunderstood as neglect or abuse and recommends assessment for safeguarding of persons suspected of having ME/CFS be evaluated by professionals with experience and understanding of the illness. Clinical management varies widely, with many patients receiving combinations of therapies.[94]: 9 

Comorbid conditions that may interact with and worsen ME/CFS symptoms care are common, and treating these may be beneficial. The most commonly diagnosed include fibromyalgia, irritable bowel syndrome, depression, anxiety, allergies, and chemical sensitivities.[95]

Pacing and energy envelope

Spoons are used as a metaphor and visual representation for energy rationing.

Pacing, or activity management, is a management strategy based on the observation that symptoms tend to increase following mental or physical exertion.[8] It was developed for ME/CFS in the 1980s,[96] and is now commonly used as a management strategy in chronic illnesses and in chronic pain.[97]

Its two forms are symptom-contingent pacing, in which the decision to stop (and rest or change an activity) is determined by self-awareness of an worsening of symptoms, and time-contingent pacing, which is determined by a set schedule of activities that a patient estimates they can complete without triggering post-exertional malaise (PEM). Thus, the principle behind pacing for ME/CFS is to avoid overexertion and an exacerbation of symptoms. It is not aimed at treating the illness as a whole. Those whose illness appears stable may gradually increase activity and exercise levels, but according to the principle of pacing, must rest or reduce their activity levels if it becomes clear that they have exceeded their limits.[96][21]

Energy envelope theory, consistent with pacing, states that patients should stay within, and avoid pushing through, the envelope of energy available to them, so as to reduce the post-exertional malaise "payback" caused by overexertion. This may help them make "modest gains" in physical functioning.[98][99] Use of a heart-rate monitor with pacing to monitor and manage activity levels is recommended by a number of patient groups,[100] and the CDC considers it useful for some individuals to help avoid post-exertional malaise.[8]

Several studies have found energy envelope theory to be a helpful management strategy, noting that it reduces symptoms and may increase the level of functioning in ME/CFS.[99] A 2023 review of pacing studies stated that while most trials found a positive effects, studies were typically small and rarely included a way to tell if patients implemented pacing well.[101]

Exercise

Stretching, movement therapies, and toning exercises are recommended for pain in people with ME/CFS. In many chronic illnesses, aerobic exercise is beneficial, but in chronic fatigue syndrome, the CDC does not recommend it. The CDC states:[8]

Any activity or exercise plan for people with ME/CFS needs to be carefully designed with input from each patient. While vigorous aerobic exercise can be beneficial for many chronic illnesses, patients with ME/CFS do not tolerate such exercise routines. Standard exercise recommendations for healthy people can be harmful for patients with ME/CFS. However, it is important that patients with ME/CFS undertake activities that they can tolerate...

Short periods of low-intensity exercise to improve stamina may be possible in a subset of people with ME/CFS. Exercise should only be attempted after pacing has been implemented effectively.[15] The amount of exercise should be varied based on the symptom severity of each day, to avoid PEM.[91]

Graded exercise therapy (GET), a proposed treatment for ME/CFS which involves fixed increments in exercise over time, is not recommended for people with ME/CFS.[37][91]: 37 

Counseling

Chronic illness often impacts mental health.[15] Psychotherapy may help people with ME/CFS manage the stress of being ill, apply self-management strategies for their symptoms, and cope with physical pain.[21][8] Cognitive behavioral therapy (CBT) may be offered to people with a new ME/CFS diagnosis to give them tools to cope with the disease and help with rehabilitation. Family sessions may be useful to teach about the severe disability from ME/CFS.[91]: 39 Depression or anxiety resulting from ME/CFS is common,[15] and CBT may be a useful treatment.[91]: 40 

Diet and nutrition

A proper diet is a significant contributor to the health of any individual. Medical consultation about diet and supplements is recommended for persons with ME/CFS.[8] Persons with ME/CFS may also benefit from nutritional support if deficiencies are detected by medical testing. However, nutritional supplements may interact with prescribed medication.[102][8]

Bowel issues are a common symptom of ME/CFS. For some, eliminating certain food groups, such as caffeine, alcohol or dairy, can alleviate symptoms.[15] People with severe ME/CFS may have significant trouble getting nutrition. Intravenous feeding (via blood) or tube feeding may be necessary to address this, or to address electrolyte imbalances.[37]

Proposed treatments

There are no approved treatments for ME/CFS. Cognitive behavior therapy (CBT) and graded exercise therapy (GET) have been proposed, but their safety and efficacy are disputed.[103][104] The drug rintatolimod has been trialed and has been approved in Argentina.[105]

Cognitive behavioral therapy

NICE only recommends CBT for help coping with distress the illness causes. The guidelines emphasize that CBT for people with ME/CFS, not assume unhelpful beliefs cause their illness, and not represent it as curative.[89] Similarly, the CDC stopped recommending CBT as a treatment in 2017, recommending counseling as a coping method instead.[106][8]

Certain types of CBT for ME/CFS operate on the idea that individuals with ME/CFS mistakenly believe their illness is purely physical. According to this model, their fear of triggering symptoms can prolong their condition, creating a harmful cycle of avoiding activity and becoming less physically active. This model has been criticized as lacking evidence and being at odds with the biological changes associated with ME/CFS. The use of this type of CBT has been controversial,[103][104] and NICE removed their recommendation for this form in 2021.[89]

Graded exercise therapy

Main article: Graded exercise therapy

Graded exercise therapy (GET) is a programme of physical therapy that starts at a patient's baseline and increases over time in fixed increments. Like forms of CBT that seeks to challenge patients beliefs of their illness, it assumes that fear of activity and deconditioning play a significant role in their illness.[89][8] Reviews of GET either see weak evidence of a small to moderate effect[94][107] or no evidence of effectiveness.[103][104] Few clinical trials contained enough detail about adverse effects.[94] There are reports of serious adverse effects from GET.[16]: 160 

The 2021 NICE guidelines removed GET as a recommended treatment due to low quality evidence regarding benefit, with the guidelines now telling clinicians not to prescribe "any programme that ... uses fixed incremental increases in physical activity or exercise, for example, graded exercise therapy."[21] The CDC withdrew their recommendation for GET in 2017.[106]

Rintatolimod

Rintatolimod is a double-stranded RNA drug developed to modulate an antiviral immune reaction through activation of toll-like receptor 3. In several clinical trials of ME/CFS, the treatment has shown a reduction in symptoms, but improvements were not sustained after discontinuation.[108] Evidence supporting the use of rintatolimod is deemed low to moderate.[22] The US Food and Drug Administration (FDA) has denied commercial approval, called a new drug application, citing several deficiencies and gaps in safety data in the trials, and concluded that the available evidence is insufficient to demonstrate its safety or efficacy in ME/CFS.[109][110] Rintatolimod has been approved for marketing and treatment for persons with ME/CFS in Argentina.[105]

Prognosis

Information on the prognosis of ME/CFS is limited, and the course of the illness is variable.[111] According to the NICE guideline, ME/CFS "varies in long-term outlook from person to person."[112] Complete recovery, partial improvement, and worsening are all possible.[111] Symptoms generally fluctuate over days, weeks, or longer periods, and some people may experience periods of remission.[112] Overall, "many will need to adapt to living with ME/CFS."[112] Some people who improve need to manage their activities in order to prevent relapse.[111] Children and teenagers are more likely to recover or improve than adults.[111][112]

A 2005 systematic review found that for untreated CFS, "the median full recovery rate was 5% (range 0–31%) and the median proportion of patients who improved during follow-up was 39.5% (range 8–63%)," and that 8 to 30% of patients were able to return to work. Age at onset, a longer duration of follow-up, less fatigue severity at baseline, and other factors were occasionally, but non consistently, related to outcome.[113] Children and teenagers have a better prognosis than adults. For instance, a study in Australia among 6- to 18-year olds found two thirds reported recovery after ten years, and that the typical duration of illness was 5 year.[16]: 11 

Epidemiology

Graph showing that people most frequently get CFS between the ages of 10 and 39, and that it is about 3 times as common in females
Incidence rates by age and sex, from a 2014 study in Norway

Reported prevalence rates vary widely depending on how CFS/ME is defined and diagnosed.[11] Based on the 1994 CDC diagnostic criteria, the global prevalence rate for CFS is 0.89%.[11] In comparison, estimates using the 1988 CDC "Holmes" criteria and 2003 Canadian criteria for ME produced an incidence rate of only 0.17%.[11]

As of 2015, between 836,000 and 2.5 million Americans were estimated to have ME/CFS, with 84–91% of these being undiagnosed.[2]: 1 In England and Wales, over 250,000 people are estimated to be affected.[114] The worldwide prevalence is 17 and 24 million.[11] These estimates are based on data before the COVID-19 pandemic. It is likely that numbers have increased as a large share of people with Long COVID meet the diagnostic criteria of ME/CFS.[16]: 29, 228  A 2021-2022 CDC survey found that 1.3% of adults in the United States, or 3.3 million, had ME/CFS.[115]

Females are diagnosed about 1.5 to 2.0 times more often with CFS/ME than males.[11] An estimated 0.5% of children have ME/CFS, and more adolescents are affected with the illness than younger children.[2]: 182 [24]

The incidence rate according to age has two peaks, one at 10–19 and another at 30–39 years,[4] and the rate of prevalence is highest between ages 40 and 60.[42][116]

History

Main article: History of chronic fatigue syndrome

Myalgic encephalomyelitis

  • From 1934 onwards, outbreaks of a previously unknown illness began to be recorded by doctors.[117][118] Initially considered to be occurrences of poliomyelitis, the illness was subsequently referred to as "epidemic neuromyasthenia".[118]
  • In the 1950s, the term "benign myalgic encephalomyelitis" was used in relation to a comparable outbreak at the Royal Free Hospital in London.[119] The descriptions of each outbreak were varied, but included symptoms of malaise, tender lymph nodes, sore throat, pain, and signs of encephalomyelitis.[120] The cause of the condition was not identified, although it appeared to be infectious, and the term "benign myalgic encephalomyelitis" was chosen to reflect the lack of mortality, the severe muscular pains, symptoms suggesting damage to the nervous system, and to the presumed inflammatory nature of the disorder. Björn Sigurðsson disapproved of the name, stating that the illness is rarely benign, does not always cause muscle pain, and is possibly never encephalomyelitic.[117] The syndrome appeared in sporadic as well as epidemic cases.[121]
  • In 1969, benign myalgic encephalomyelitis appeared as an entry to the International Classification of Diseases under Diseases of the nervous system.[122]
  • In 1986, Ramsay published the first diagnostic criteria for ME, in which the condition was characterized by: 1) muscle fatiguability in which, even after minimal physical effort, three or more days elapse before full muscle power is restored; 2) extraordinary variability or fluctuation of symptoms, even in the course of one day; and 3) chronicity.[123]
  • By 1988, the continued work of Ramsay had demonstrated that, although the disease rarely resulted in mortality, it was often severely disabling.[2]: 28–29  Because of this, Ramsay proposed that the prefix "benign" be dropped.[119][124][125]

Chronic fatigue syndrome

  • In the 1980s, two large outbreaks of an illness that resembled mononucleosis drew national attention in the United States. Located in Nevada and New York, the outbreaks involved an illness characterized by "chronic or recurrent debilitating fatigue, and various combinations of other symptoms, including a sore throat, lymph node pain and tenderness, headache, myalgia, and arthralgias". An initial link to the Epstein–Barr virus had the illness acquire the name "chronic Epstein–Barr virus syndrome".[2]: 29 [85]
  • In 1987, the CDC convened a working group to reach a consensus on the clinical features of the illness. The working group concluded that CFS was not new, and that the many different names given to it previously reflected widely differing concepts of the illness's cause and epidemiology.[126] The CDC working group chose "chronic fatigue syndrome" as a more neutral and inclusive name for the illness, but noted that "myalgic encephalomyelitis" was widely accepted in other parts of the world.[85]
  • In 1988, the first definition of CFS was published. Although the cause of the illness remained unknown, several attempts were made to update this definition, most notably in 1994.[84]
  • The most widely referenced diagnostic criteria and definition of CFS for research and clinical purposes were published in 1994 by the CDC.[55]
  • In 2006, the CDC commenced a national program to educate the American public and health-care professionals about CFS.[127]

Other medical terms

A range of both theorised and confirmed medical entities and naming conventions have appeared historically in the medical literature dealing with ME and CFS. These include:

  • Epidemic neuromyasthenia was a term used for outbreaks with symptoms resembling poliomyelitis.[117][128]
  • Iceland disease and Akureyri disease were synonymous terms used for an outbreak of fatigue symptoms in Iceland.[129]
  • Low natural killer syndrome, a term used mainly in Japan, reflected research showing diminished in vitro activity of natural killer cells isolated from patients.[130][131]
  • Neurasthenia had been proposed as a historical diagnosis that occupied a similar medical and cultural space to CFS.[132]
  • Royal Free disease was named after the historically significant outbreak in 1955 at the Royal Free Hospital used as an informal synonym for "benign myalgic encephalomyelitis".[133]
  • Tapanui flu was a term commonly used in New Zealand, deriving from the name of a town, Tapanui, where numerous people had the syndrome.[134]

Society and culture

Presentation of a petition to the National Assembly for Wales relating to ME support in South East Wales

Naming

Many names have been proposed for the illness. Currently, the most commonly used are "chronic fatigue syndrome", "myalgic encephalomyelitis", and the umbrella term "myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)". Reaching consensus on a name is challenging because the cause and pathology remain unknown.[2]: 29–30 

Many patients object to the term "chronic fatigue syndrome". They consider the term too simplistic and trivialising, which in turn prevents the illness from being taken seriously.[2]: 234 [135] At the same time, there are also issues with the use of "myalgic encephalomyelitis, as there is only limited evidence of brain inflammation implied by the name.[91]: 3  The umbrella term ME/CFS would retain the better-known phrase CFS without trivialising the disease, but some people object to this name too as they see CFS and ME as distinct illnesses.[135]

A 2015 report from the Institute of Medicine recommended the illness be renamed "systemic exertion intolerance disease", (SEID), and suggested new diagnostic criteria, proposing post-exertional malaise (PEM), impaired function, and sleep problems are core symptoms of ME/CFS.[2] While the new name was not widely adopted, the diagnostic criteria were taken over by the CDC. Like CFS, SEID only focuses on a single symptom and patient opinions have generally been negative.[136]

Economic impact

Economic costs due to CFS are "significant".[39] A 2021 paper by Leonard Jason and Arthur Mirin estimated the impact in the US to be $36-51 billion per year, or $31,592 to $41,630 per person, considering both lost wages and healthcare costs.[137] The CDC estimated direct healthcare costs alone at $9–14 billion annually.[39] A 2017 estimate for the annual economic burden in the United Kingdom was £3.3 billion.[17]

Awareness day

12 May is designated as ME/CFS International Awareness Day.[138] The day is observed so that stakeholders have an occasion to improve the knowledge of "the public, policymakers, and health-care professionals about the symptoms, diagnosis, and treatment of ME/CFS, as well as the need for a better understanding of this complex illness."[139] It was chosen because it is the birthday of Florence Nightingale, who had an illness appearing similar to ME/CFS or fibromyalgia.[138][140]

Doctor–patient relations

People with ME/CFS face stigma in healthcare settings, and doctors may have trouble managing an illness that lacks a clear cause or treatment.[2]: 30 [26] There has been much disagreement over proposed causes, diagnosis, and treatment of the illness.[141][142][143][144] Some doctors believe it is psychological.[2]: 234 [145] Most patients are convinced their illness is physical instead, straining doctor-patient relationships.[26] Clinicians may be unfamiliar with ME/CFS, as it is often not covered in medical school.[146][26] Due to this unfamiliarity, people may go undiagnosed for years,[15]: 2861 [2]: 1  or be misdiagnosed with mental conditions.[146][15]: 2871  A substantial portion of doctors are uncertain about how to diagnose or manage CFS.[145] In a 2006 survey of GPs in southwest England, 75% accepted it as a "recognisable clinical entity", but 48% did not feel confident in diagnosing it, and 41% in managing it.[147][145]

The NAM report refers to CFS as "stigmatized", and the majority of patients report negative healthcare experiences.[2]: 30 [26] These patients may feel that their doctor inappropriately calls their illness psychological or doubts the severity of their symptoms.[26] They may also feel forced to prove that they are legitimately ill.[148] Some may be given outdated treatments that provoke symptoms or assume their illness is due to unhelpful thoughts and deconditioning.[2]: 25 [15]: 2871 [146] In a 2009 survey, only 35% of patients considered their physicians experienced with CFS and only 23% thought their doctors knew enough to treat it.[145]

Blood donation

In 2010, several national blood banks adopted measures to discourage or prohibit individuals diagnosed with CFS from donating blood, based on concern following the 2009 claim of a link[149] between CFS and a retrovirus which was subsequently shown to be unfounded. Organizations adopting these or similar measures included the Canadian Blood Services,[150] the New Zealand Blood Service,[151] the Australian Red Cross Blood Service[152] and the American Association of Blood Banks.[153] In November 2010, the UK National Blood Service permanently deferred ME/CFS patients from donating blood to prevent potential harm to the donor.[154] Donation policy in the UK now states, "The condition is relapsing by nature and donation may make symptoms worse, or provoke a relapse in an affected individual."[155]

Controversy

Main article: Controversies related to chronic fatigue syndrome

Much contention has arisen over the cause, pathophysiology,[156] name,[157] and diagnostic criteria of ME/CFS.[28][142] Historically, many professionals within the medical community were unfamiliar with CFS, or did not recognize it as a real condition; nor did agreement exist on its prevalence or seriousness.[158][159][160] ME/CFS patients often recognise that their doctors attribute their illness to a psychological origin, but they strongly disagree with a psychosomatic origin for their illness.[161]

In 1970, two British psychiatrists, McEvedy and Beard, reviewed the case notes of 15 outbreaks of benign myalgic encephalomyelitis and concluded that it was caused by mass hysteria on the part of patients, or altered medical perception of the attending physicians.[162] Their conclusions were based on previous studies that found many normal physical test results, a lack of a discernible cause, and a higher prevalence of the illness in females. Consequently, the authors recommended that the disease should be renamed "myalgia nervosa". This perspective was rejected in a series of case studies by Melvin Ramsay and other staff of the Royal Free Hospital, the center of a significant outbreak.[163] The psychological hypothesis posed by McEvedy and Beard created great controversy, and convinced a generation of health professionals in the UK that this could be a plausible explanation for the condition, resulting in neglect by many medical specialties.[164] The specialty that did take a major interest in the illness was psychiatry.[165]

Because of the controversy, sociologists hypothesized that stresses of modern living might be a cause of the illness, while some in the media used the term "Yuppie flu" and called it a disease of the middle class.[165] People with disabilities from CFS were often not believed and were accused of being malingerers.[165] The November 1990 issue of Newsweek ran a cover story on CFS, which although supportive of an organic cause of the illness, also featured the term 'yuppie flu', reflecting the stereotype that CFS mainly affected yuppies. The implication was that CFS is a form of burnout. The term 'yuppie flu' is considered offensive by both patients and clinicians.[166][167]

In 2009, the journal Science[149] published a study that identified the XMRV retrovirus in a population of people with CFS. Other studies failed to reproduce this finding,[168][169][170] and in 2011, the editor of Science formally retracted its XMRV paper[171] while the Proceedings of the National Academy of Sciences similarly retracted a 2010 paper which had appeared to support the finding of a connection between XMRV and CFS.[172]

Research funding

Historical research funding for ME/CFS has been far below that of comparable diseases.[27][173] In a 2015 report, the U.S. National Academy of Sciences called it "remakabl[e]" how little funding there had been for research into causes, mechanisms and treatment.[2]: 9  Lower funding levels have led to a smaller number and size of studies.[174] In addition, drug companies have invested very little in the disease.[175]

The U.S. National Institutes of Health (NIH) is the largest biomedical funder worldwide.[176] Using rough estimates of disease burden, a study found NIH funding for ME/CFS was only 3% to 7% of the average disease per healthy life year lost between 2015 and 2019.[177] Worldwide, multiple sclerosis, which affects fewer people and results in disability no worse than ME/CFS, received 20 times as much funding between 2007 and 2015.[173]

Multiple reasons have been proposed for the low funding levels. Diseases for which society "blames the victim" are frequently underfunded. This may explain why a severe lung disease often caused by smoking receives low funding per healthy life year lost.[178] Similarly for ME/CFS, the historical belief that it is caused by psychological factors, may have contributed to lower funding. Gender bias may also play a role; the NIH spends less on diseases which predominantly affect women in relation to disease burden. Less well funded research areas may also struggle competing with more mature areas of medicine for the same grants.[177]

Notable cases

Main article: List of people with chronic fatigue syndrome

In 1989, The Golden Girls (1985–1992) featured chronic fatigue syndrome in a two-episode arc, "Sick and Tired: Part 1" and "Part 2", in which protagonist Dorothy Zbornak, portrayed by Bea Arthur, after a lengthy battle with her doctors in an effort to find a diagnosis for her symptoms, is finally diagnosed with CFS.[179] American author Ann Bannon had CFS.[180] Laura Hillenbrand, author of the popular book Seabiscuit, has struggled with CFS since age 19.[181][182]

Research

Graph of ME/CFS papers published by year, showing an increasing trend since about 1985
Graph of CFS papers published by year:
  Papers mentioning ME or CFS
  Papers whose title mentions ME/CFS

Current research into ME/CFS may lead to a better understanding of the disease's causes, biomarkers to aid in diagnosis, and treatments to relieve symptoms.[2]: 10  The emergence of long COVID has sparked increased interest in ME/CFS, as the two conditions may share pathology, and a treatment for one may treat the other.[183]

Causes

Recent research suggests dysfunction in many biological processes. These changes may share a common cause, but the true relationship between them is currently unknown. Metabolic areas of interest include disruptions in amino acid metabolism, the TCA cycle, ATP synthesis, and potentially increased lipid metabolism. Other research has investigated immune dysregulation and its potential connections to mitochondrial dysfunction. Autoimmunity has been proposed as a cause, but evidence is scant. People with ME/CFS may have abnormal gut microbiota, which has been proposed to affect mitochondria or nervous system function.[184]

Several small studies have investigated the genetics of ME/CFS, but none of their findings have been replicated.[185] A larger study, DecodeME, is currently underway in the United Kingdom.[186]

Treatments

Various drug treatments for ME/CFS are being explored. The types of drugs under investigation often target the nervous system, the immune system, autoimmunity, or pain directly. More recently, there has been a growing interest in drugs targeting energy metabolism.[175]

Drugs targetting the immune system include rintatolimod.[175] Low-dose naltrexone, which works against neuro-inflammation, is being studied as of 2023.[187] Rituximab, a drug that depletes B cells, was studied and found to be ineffective.[184] Other options targetting auto-immunity are immune absorption, whereby a large set of (auto)antibodies is removed from the blood.[175]

Biomarkers

Many biomarkers for ME/CFS have been proposed based on research findings. But due to the use of a number of case definitions in research, some of which are non-specific such as the Sharpe ("Oxford") and Fukuda ("old CDC") definitions, no biomarkers have been widely validated or broadly clinically implemented.[184] Proposed markers include electrical measurements of blood cells and a combination of immune cell death rate and function.[187]

Challenges

ME/CFS affects multiple bodily systems, varies widely in severity, and fluctuates over time, creating heterogeneity within patient groups and making it very difficult to identify a singular cause. This variation may also cause treatments that are effective for some to have no effect or a negative effect in others.[187] Dividing people with ME/CFS into subtypes may help manage this heterogeneity.[184]

The existence of multiple diagnostic criteria, and variations in how scientists apply them, complicate comparisons between studies.[2]: 53 [184] Some definitions, like the Oxford and Fukuda criteria, may fail to distinguish between chronic fatigue in general and ME/CFS, which requires PEM in modern definitions.[184] Definitions also vary in which co-occurring conditions preclude a diagnosis of ME/CFS.[2]: 52 

References

  1. ^ a b c d e "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)". U.S. Centers for Disease Control and Prevention (CDC). 13 April 2020. Archived from the original on 22 August 2020. Retrieved 20 May 2020.
  2. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome; Board on the Health of Select Populations; Institute of Medicine (10 February 2015). Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness (PDF). PMID 25695122. Archived (PDF) from the original on 20 January 2017. Retrieved 28 July 2020.
  3. ^ "Recommendations – Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management – Guidance". National Institute for Health and Care Excellence (NICE). 29 October 2021. Archived from the original on 29 December 2021. Retrieved 15 January 2022.
  4. ^ a b Collard SS, Murphy J (September 2020). "Management of chronic fatigue syndrome/myalgic encephalomyelitis in a pediatric population: A scoping review". Journal of Child Health Care. 24 (3): 411–431. doi:10.1177/1367493519864747. PMC 7863118. PMID 31379194.
  5. ^ "Information for the public | Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management | Guidance | NICE". www.nice.org.uk. 29 October 2021. Retrieved 10 December 2023.
  6. ^ a b c "Possible Causes". U.S. Centers for Disease Control and Prevention (CDC). 15 May 2019. Archived from the original on 22 August 2020. Retrieved 20 May 2020.
  7. ^ a b c Carruthers BM, van de Sande MI, De Meirleir KL, Klimas NG, Broderick G, Mitchell T, et al. (International Consensus Panel) (2012). "Myalgic Encephalomyelitis – Adult & Paediatric: International Consensus Primer for Medical Practitioners" (PDF). Archived from the original (PDF) on 10 July 2020.
  8. ^ a b c d e f g h i j k l m n "Treatment of ME/CFS". Centers for Disease Control and Prevention. 28 January 2021. Archived from the original on 20 March 2021. Retrieved 9 October 2023. Public Domain This article incorporates text from this source, which is in the public domain.
  9. ^ "Publication of Cochrane Review: 'Exercise therapy for chronic fatigue syndrome'". www.cochrane.org. 21 May 2020. Archived from the original on 17 June 2020. Retrieved 24 May 2020. It now places more emphasis on the limited applicability of the evidence to definitions of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) used in the included studies, the long-term effects of exercise on symptoms of fatigue, and acknowledges the limitations of the evidence about harms that may occur.
  10. ^ a b Sandler CX, Lloyd AR (May 2020). "Chronic fatigue syndrome: progress and possibilities". The Medical Journal of Australia. 212 (9): 428–433. doi:10.5694/mja2.50553. PMID 32248536. S2CID 214810583.
  11. ^ a b c d e f g h i Lim EJ, Ahn YC, Jang ES, Lee SW, Lee SH, Son CG (February 2020). "Systematic review and meta-analysis of the prevalence of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME)". Journal of Translational Medicine. 18 (1): 100. doi:10.1186/s12967-020-02269-0. PMC 7038594. PMID 32093722.
  12. ^ "Information for Healthcare Providers". U.S. Centers for Disease Control and Prevention (CDC). 13 April 2020. Archived from the original on 9 August 2020. Retrieved 17 June 2020.
  13. ^ a b c d e f g "Symptoms of ME/CFS". U.S. Centers for Disease Control and Prevention (CDC). 19 November 2019. Archived from the original on 22 August 2020. Retrieved 20 May 2020.
  14. ^ a b c d e "Etiology and Pathophysiology". U.S. Centers for Disease Control and Prevention (CDC). 12 July 2018. Archived from the original on 18 July 2018. Retrieved 8 March 2022.
  15. ^ a b c d e f g h i j k l m n o Bateman L, Bested AC, Bonilla HF, Chheda BV, Chu L, Curtin JM, et al. (November 2021). "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Essentials of Diagnosis and Management". Mayo Clinic Proceedings. 96 (11): 2861–2878. doi:10.1016/j.mayocp.2021.07.004. PMID 34454716. S2CID 237419583.
  16. ^ a b c d e f g h i Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG) (17 April 2023). Myalgische Enzephalomyelitis / Chronic Fatigue Syndrome (ME/CFS): Aktueller Kenntnisstand [Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS): current state of knowledge] (PDF) (in German). Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen. ISSN 1864-2500.
  17. ^ a b c d Dibble JJ, McGrath SJ, Ponting CP (September 2020). "Genetic risk factors of ME/CFS: a critical review". Human Molecular Genetics. 29 (R1): R117–R124. doi:10.1093/hmg/ddaa169. PMC 7530519. PMID 32744306.
  18. ^ a b c d e Maksoud R, du Preez S, Eaton-Fitch N, Thapaliya K, Barnden L, Cabanas H, et al. (2020). "A systematic review of neurological impairments in myalgic encephalomyelitis/ chronic fatigue syndrome using neuroimaging techniques". PLOS ONE. 15 (4): e0232475. Bibcode:2020PLoSO..1532475M. doi:10.1371/journal.pone.0232475. PMC 7192498. PMID 32353033.
  19. ^ a b Estévez-López F, Mudie K, Wang-Steverding X, Bakken IJ, Ivanovs A, Castro-Marrero J, et al. (May 2020). "Systematic Review of the Epidemiological Burden of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Across Europe: Current Evidence and EUROMENE Research Recommendations for Epidemiology". Journal of Clinical Medicine. 9 (5). MDPI AG: 1557. doi:10.3390/jcm9051557. PMC 7290765. PMID 32455633.
  20. ^ a b "Severely Affected Patients – Clinical Care of Patients – Healthcare Providers – Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)". U.S. Centers for Disease Control and Prevention (CDC). 19 November 2019. Archived from the original on 11 December 2020. Retrieved 30 November 2020.
  21. ^ a b c d e "Recommendations – Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management – Guidance". National Institute for Health and Care Excellence (NICE). 29 October 2021. Archived from the original on 29 December 2021. Retrieved 15 January 2022.
  22. ^ a b Smith ME, Haney E, McDonagh M, Pappas M, Daeges M, Wasson N, et al. (June 2015). "Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop". Annals of Internal Medicine (Systematic review). 162 (12): 841–850. doi:10.7326/M15-0114. PMID 26075755. S2CID 28576363.
  23. ^ a b c d "Epidemiology". U.S. Centers for Disease Control and Prevention (CDC). 12 July 2018. Archived from the original on 6 June 2020. Retrieved 24 May 2020.
  24. ^ a b c "ME/CFS in Children". U.S. Centers for Disease Control and Prevention (CDC). 15 May 2019. Archived from the original on 28 July 2020. Retrieved 24 May 2020. ME/CFS is often thought of as a problem in adults, but children (both adolescents and younger children) can also get ME/CFS.
  25. ^ Boulazreg S, Rokach A (October 2020). "The Lonely, Isolating, and Alienating Implications of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome". Healthcare. 8 (4): 413. doi:10.3390/healthcare8040413. PMC 7711762. PMID 33092097.
  26. ^ a b c d e f McManimen S, McClellan D, Stoothoff J, Gleason K, Jason LA (March 2019). "Dismissing chronic illness: A qualitative analysis of negative health care experiences". Health Care for Women International. 40 (3): 241–258. doi:10.1080/07399332.2018.1521811. PMC 6567989. PMID 30829147.
  27. ^ a b Tyson S, Stanley K, Gronlund TA, Leary S, Emmans Dean M, Dransfield C, et al. (2022). "Research priorities for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS): the results of a James Lind alliance priority setting exercise". Fatigue: Biomedicine, Health & Behavior. 10 (4): 200–211. doi:10.1080/21641846.2022.2124775. ISSN 2164-1846. S2CID 252652429.
  28. ^ a b O'Leary, Diane (2019). "Ethical classification of ME/CFS in the United Kingdom". Bioethics. 33 (6): 716–722. doi:10.1111/bioe.12559. ISSN 0269-9702. PMID 30734339. S2CID 73450577.
  29. ^ Bateman, Lucinda (2022). "Fibromyalgia and myalgic encephalomyelitis/chronic fatigue syndrome". In Zigmond, Michael; Wiley, Clayton; Chesselet, Marie-Francoise (eds.). Neurobiology of Brain Disorders : Biological Basis of Neurological and Psychiatric Disorders (2nd ed.). Elsevier. p. 564. ISBN 9780323856546.
  30. ^ Shan ZY, Barnden LR, Kwiatek RA, Bhuta S, Hermens DF, Lagopoulos J (September 2020). "Neuroimaging characteristics of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS): a systematic review". Journal of Translational Medicine. 18 (1): 335. doi:10.1186/s12967-020-02506-6. PMC 7466519. PMID 32873297.
  31. ^ "ICD-11 – Mortality and Morbidity Statistics". icd.who.int. Archived from the original on 1 August 2018. Retrieved 20 May 2020. Diseases of the nervous system
  32. ^ a b Lim EJ, Son CG (July 2020). "Review of case definitions for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)". Journal of Translational Medicine. 18 (1): 289. doi:10.1186/s12967-020-02455-0. PMC 7391812. PMID 32727489.
  33. ^ a b "Treating the Most Disruptive Symptoms First and Preventing Worsening of Symptoms". U.S. Centers for Disease Control and Prevention (CDC). 19 November 2019. Archived from the original on 7 August 2020. Retrieved 19 August 2020.
  34. ^ a b Nijs J, Meeus M, Van Oosterwijck J, Ickmans K, Moorkens G, Hans G, De Clerck LS (February 2012). "In the mind or in the brain? Scientific evidence for central sensitisation in chronic fatigue syndrome". European Journal of Clinical Investigation. 42 (2): 203–212. doi:10.1111/j.1365-2362.2011.02575.x. PMID 21793823. S2CID 13926525.
  35. ^ a b O'Boyle S, Nacul L, Nacul FE, Mudie K, Kingdon CC, Cliff JM, et al. (2021). "A Natural History of Disease Framework for Improving the Prevention, Management, and Research on Post-viral Fatigue Syndrome and Other Forms of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome". Frontiers in Medicine. 8: 688159. doi:10.3389/fmed.2021.688159. PMC 8835111. PMID 35155455.
  36. ^ a b c d e f "Presentation and Clinical Course of ME/CFS". U.S. Centers for Disease Control and Prevention (CDC). 19 November 2019. Archived from the original on 28 July 2020. Retrieved 11 July 2020.
  37. ^ a b c d Grach SL, Seltzer J, Chon TY, Ganesh R (October 2023). "Diagnosis and Management of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome". Mayo Clinic Proceedings. 98 (10): 1544–1551. doi:10.1016/j.mayocp.2023.07.032. PMID 37793728. S2CID 263665180.
  38. ^ a b c "What is ME/CFS?". U.S. Centers for Disease Control and Prevention (CDC). 12 July 2018. Archived from the original on 17 August 2020. Retrieved 21 May 2020.
  39. ^ a b c "Chronic Fatigue Syndrome: Advancing Research and Clinical Education". Centers for Disease Control and Prevention. 28 February 2018. Archived from the original on 28 July 2020. Retrieved 26 May 2020.
  40. ^ Ross SD, Estok RP, Frame D, Stone LR, Ludensky V, Levine CB (May 2004). "Disability and chronic fatigue syndrome: a focus on function". Archives of Internal Medicine. 164 (10): 1098–1107. doi:10.1001/archinte.164.10.1098. PMID 15159267. S2CID 1381888.
  41. ^ Meeus M, Nijs J, Meirleir KD (May 2007). "Chronic musculoskeletal pain in patients with the chronic fatigue syndrome: a systematic review". European Journal of Pain. 11 (4): 377–386. doi:10.1016/j.ejpain.2006.06.005. PMID 16843021. S2CID 21414690.
  42. ^ a b c d e f g Unger ER, Lin JS, Brimmer DJ, Lapp CW, Komaroff AL, Nath A, et al. (December 2016). "CDC Grand Rounds: Chronic Fatigue Syndrome - Advancing Research and Clinical Education" (PDF). MMWR. Morbidity and Mortality Weekly Report. 65 (50–51): 1434–1438. doi:10.15585/mmwr.mm655051a4. PMID 28033311. Archived (PDF) from the original on 6 January 2017. Retrieved 5 January 2017. The highest prevalence of illness is in persons aged 40–50 years...
  43. ^ Falk Hvidberg M, Brinth LS, Olesen AV, Petersen KD, Ehlers L (6 July 2015). Furlan R (ed.). "The Health-Related Quality of Life for Patients with Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS)". PLOS ONE. 10 (7): e0132421. Bibcode:2015PLoSO..1032421F. doi:10.1371/journal.pone.0132421. PMC 4492975. PMID 26147503.
  44. ^ Christley Y, Duffy T, Everall IP, Martin CR (April 2013). "The neuropsychiatric and neuropsychological features of chronic fatigue syndrome: revisiting the enigma". Current Psychiatry Reports. 15 (4): 353. doi:10.1007/s11920-013-0353-8. PMID 23440559. S2CID 25790262.
  45. ^ a b c Cvejic E, Birch RC, Vollmer-Conna U (May 2016). "Cognitive Dysfunction in Chronic Fatigue Syndrome: a Review of Recent Evidence". Current Rheumatology Reports. 18 (5). Springer Science and Business Media LLC: 24. doi:10.1007/s11926-016-0577-9. PMID 27032787. S2CID 38748839.
  46. ^ "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome – Etiology and Pathophysiology". 10 July 2018. Archived from the original on 18 July 2018. Retrieved 18 July 2018.
  47. ^ "Chronic fatigue syndrome (CFS)". Department of Health, State Government of Victoria, Australia. 7 July 2022. Retrieved 1 February 2023.
  48. ^ Rasa S, Nora-Krukle Z, Henning N, Eliassen E, Shikova E, Harrer T, et al. (October 2018). "Chronic viral infections in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)". Journal of Translational Medicine. 16 (1): 268. doi:10.1186/s12967-018-1644-y. PMC 6167797. PMID 30285773.
  49. ^ Altmann DM, Whettlock EM, Liu S, Arachchillage DJ, Boyton RJ (October 2023). "The immunology of long COVID". Nature Reviews. Immunology. 23 (10): 618–634. doi:10.1038/s41577-023-00904-7. PMID 37433988. S2CID 259831825.
  50. ^ Bonilla, Hector; Quach, Tom C.; Tiwari, Anushri; Bonilla, Andres E.; Miglis, Mitchell; Yang, Phillip C.; Eggert, Lauren E.; Sharifi, Husham; Horomanski, Audra; Subramanian, Aruna; Smirnoff, Liza; Simpson, Norah; Halawi, Houssan; Sum-ping, Oliver; Kalinowski, Agnieszka (24 February 2023). "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome is common in post-acute sequelae of SARS-CoV-2 infection (PASC): Results from a post-COVID-19 multidisciplinary clinic". Frontiers in Neurology. 14. doi:10.3389/fneur.2023.1090747. ISSN 1664-2295. PMC 9998690. PMID 36908615.
  51. ^ Dinos S, Khoshaba B, Ashby D, White PD, Nazroo J, Wessely S, Bhui KS (December 2009). "A systematic review of chronic fatigue, its syndromes and ethnicity: prevalence, severity, co-morbidity and coping". International Journal of Epidemiology. 38 (6): 1554–1570. doi:10.1093/ije/dyp147. PMID 19349479.
  52. ^ Eriksen W (16 August 2018). "ME/CFS, case definition, and serological response to Epstein–Barr virus. A systematic literature review". Fatigue: Biomedicine, Health & Behavior. 6 (4): 220–34. doi:10.1080/21641846.2018.1503125. S2CID 80898744. The levels of antibodies to EBV in ME/CFS patients differed from those in controls in 14 studies. The differences in EBV serology that were revealed, were almost exclusively signs that may indicate higher EBV activity in the patient group. The serological differences between patients and controls were seen in the two studies in which ME/CFS was defined using the Canadian criteria, in 5 of the 9 studies using the Holmes criteria, in 1 of the 2 studies using modified Holmes criteria, in 2 of the 6 studies using the Fukuda criteria, and in 4 of the 7 studies using less known criteria. The single study using the Oxford criteria showed no difference between cases and controls. Conclusions: There seems to be increased EBV activity in subset(s) of ME/CFS patients.
  53. ^ Jason LA, Porter N, Brown M, Anderson V, Brown A, Hunnell J, Lerch A (2009). "CFS: A Review of Epidemiology and Natural History Studies". Bulletin of the IACFS/ME. 17 (3): 88–106. PMC 3021257. PMID 21243091.
  54. ^ a b Hulme K, Hudson JL, Rojczyk P, Little P, Moss-Morris R (August 2017). "Biopsychosocial risk factors of persistent fatigue after acute infection: A systematic review to inform interventions" (PDF). Journal of Psychosomatic Research. 99: 120–129. doi:10.1016/j.jpsychores.2017.06.013. PMID 28712416.
  55. ^ a b Brurberg KG, Fønhus MS, Larun L, Flottorp S, Malterud K (February 2014). "Case definitions for chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME): a systematic review". BMJ Open. 4 (2): e003973. doi:10.1136/bmjopen-2013-003973. PMC 3918975. PMID 24508851.
  56. ^ Lee JS, Sato W, Son CG (November 2023). "Brain-regional characteristics and neuroinflammation in ME/CFS patients from neuroimaging: A systematic review and meta-analysis". Autoimmunity Reviews. 23 (2): 103484. doi:10.1016/j.autrev.2023.103484. PMID 38016575.
  57. ^ Jason LA, Zinn ML, Zinn MA (2 February 2017). "Myalgic Encephalomyelitis: Symptoms and Biomarkers". Current Neuropharmacology. 13 (5): 701–734. doi:10.2174/1570159X13666150928105725. PMC 4761639. PMID 26411464. Decreased frontal grey matter
  58. ^ Tanaka M, Tajima S, Mizuno K, Ishii A, Konishi Y, Miike T, Watanabe Y (November 2015). "Frontier studies on fatigue, autonomic nerve dysfunction, and sleep-rhythm disorder". The Journal of Physiological Sciences. 65 (6): 483–498. doi:10.1007/s12576-015-0399-y. PMC 4621713. PMID 26420687.
  59. ^ Mohamed AZ, Andersen T, Radovic S, Del Fante P, Kwiatek R, Calhoun V, Bhuta S, Hermens DF, Lagopoulos J, Shan ZY (June 2023). "Objective sleep measures in chronic fatigue syndrome patients: A systematic review and meta-analysis". Sleep Medicine Reviews. 69: 101771. doi:10.1016/j.smrv.2023.101771. PMID 36948138.
  60. ^ Van Cauwenbergh D, Nijs J, Kos D, Van Weijnen L, Struyf F, Meeus M (May 2014). "Malfunctioning of the autonomic nervous system in patients with chronic fatigue syndrome: a systematic literature review". European Journal of Clinical Investigation. 44 (5): 516–526. doi:10.1111/eci.12256. PMID 24601948. S2CID 9722415.
  61. ^ Lapp CW (16 February 2016). "Chronic Fatigue Syndrome: Advancing Research and Clinical Education" (PDF). CDC Public Health Grand Rounds. Centers for Disease Control and Prevention. Archived (PDF) from the original on 18 October 2020. Retrieved 26 May 2020.
  62. ^ Nijs J, Nees A, Paul L, De Kooning M, Ickmans K, Meeus M, Van Oosterwijck J (2014). "Altered immune response to exercise in patients with chronic fatigue syndrome/myalgic encephalomyelitis: a systematic literature review". Exercise Immunology Review. 20: 94–116. PMID 24974723.
  63. ^ Armstrong CW, McGregor NR, Butt HL, Gooley PR (2014). "Metabolism in chronic fatigue syndrome". Advances in Clinical Chemistry. 66: 121–172. doi:10.1016/B978-0-12-801401-1.00005-0. ISBN 978-0-12-801401-1. PMID 25344988.
  64. ^ Morris G, Anderson G, Galecki P, Berk M, Maes M (March 2013). "A narrative review on the similarities and dissimilarities between myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and sickness behavior". BMC Medicine. 11: 64. doi:10.1186/1741-7015-11-64. PMC 3751187. PMID 23497361.
  65. ^ Griffith JP, Zarrouf FA (2008). "A systematic review of chronic fatigue syndrome: don't assume it's depression". Primary Care Companion to the Journal of Clinical Psychiatry. 10 (2): 120–128. doi:10.4088/pcc.v10n0206. PMC 2292451. PMID 18458765.
  66. ^ Meeus M, Mistiaen W, Lambrecht L, Nijs J (November 2009). "Immunological similarities between cancer and chronic fatigue syndrome: the common link to fatigue?". Anticancer Research. 29 (11): 4717–4726. PMID 20032425.
  67. ^ Morris G, Anderson G, Maes M (November 2017). "Hypothalamic-Pituitary-Adrenal Hypofunction in Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS) as a Consequence of Activated Immune-Inflammatory and Oxidative and Nitrosative Pathways". Molecular Neurobiology. 54 (9): 6806–6819. doi:10.1007/s12035-016-0170-2. PMID 27766535. S2CID 3524276.
  68. ^ Cho HJ, Skowera A, Cleare A, Wessely S (January 2006). "Chronic fatigue syndrome: an update focusing on phenomenology and pathophysiology". Current Opinion in Psychiatry. 19 (1): 67–73. doi:10.1097/01.yco.0000194370.40062.b0. PMID 16612182. S2CID 12815707.
  69. ^ Papadopoulos AS, Cleare AJ (September 2011). "Hypothalamic-pituitary-adrenal axis dysfunction in chronic fatigue syndrome". Nature Reviews. Endocrinology. 8 (1): 22–32. doi:10.1038/nrendo.2011.153. PMID 21946893. S2CID 22176725.
  70. ^ Tak LM, Cleare AJ, Ormel J, Manoharan A, Kok IC, Wessely S, Rosmalen JG (May 2011). "Meta-analysis and meta-regression of hypothalamic-pituitary-adrenal axis activity in functional somatic disorders". Biological Psychology. 87 (2): 183–194. doi:10.1016/j.biopsycho.2011.02.002. PMID 21315796. S2CID 206108463.
  71. ^ Van Den Eede F, Moorkens G, Van Houdenhove B, Cosyns P, Claes SJ (2007). "Hypothalamic-pituitary-adrenal axis function in chronic fatigue syndrome". Neuropsychobiology. 55 (2): 112–120. CiteSeerX 10.1.1.626.9632. doi:10.1159/000104468. PMID 17596739. S2CID 14956850.
  72. ^ Powell DJ, Liossi C, Moss-Morris R, Schlotz W (November 2013). "Unstimulated cortisol secretory activity in everyday life and its relationship with fatigue and chronic fatigue syndrome: a systematic review and subset meta-analysis". Psychoneuroendocrinology. 38 (11): 2405–2422. doi:10.1016/j.psyneuen.2013.07.004. PMID 23916911.
  73. ^ Morris G, Berk M, Galecki P, Maes M (April 2014). "The emerging role of autoimmunity in myalgic encephalomyelitis/chronic fatigue syndrome (ME/cfs)". Molecular Neurobiology. 49 (2): 741–756. doi:10.1007/s12035-013-8553-0. hdl:11343/219795. PMID 24068616. S2CID 13185036.
  74. ^ Loebel M, Grabowski P, Heidecke H, Bauer S, Hanitsch LG, Wittke K, et al. (February 2016). "Antibodies to β adrenergic and muscarinic cholinergic receptors in patients with Chronic Fatigue Syndrome". Brain, Behavior, and Immunity. 52: 32–39. doi:10.1016/j.bbi.2015.09.013. PMID 26399744.
  75. ^ Sotzny F, Blanco J, Capelli E, Castro-Marrero J, Steiner S, Murovska M, Scheibenbogen C, et al. (European Network on ME/CFS (EUROMENE)) (June 2018). "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome - Evidence for an autoimmune disease". Autoimmunity Reviews. 17 (6): 601–609. doi:10.1016/j.autrev.2018.01.009. PMID 29635081.
  76. ^ a b Wirth K, Scheibenbogen C (June 2020). "A Unifying Hypothesis of the Pathophysiology of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Recognitions from the finding of autoantibodies against ß2-adrenergic receptors". Autoimmunity Reviews. 19 (6): 102527. doi:10.1016/j.autrev.2020.102527. PMID 32247028.
  77. ^ Franklin JD, Graham M (3 July 2022). "Repeated maximal exercise tests of peak oxygen consumption in people with myalgic encephalomyelitis/chronic fatigue syndrome: a systematic review and meta-analysis". Fatigue: Biomedicine, Health & Behavior. 10 (3): 119–135. doi:10.1080/21641846.2022.2108628. ISSN 2164-1846. S2CID 251636593.
  78. ^ Holden S, Maksoud R, Eaton-Fitch N, Cabanas H, Staines D, Marshall-Gradisnik S (July 2020). "A systematic review of mitochondrial abnormalities in myalgic encephalomyelitis/chronic fatigue syndrome/systemic exertion intolerance disease". Journal of Translational Medicine. 18 (1): 290. doi:10.1186/s12967-020-02452-3. PMC 7392668. PMID 32727475.
  79. ^ Maksoud R, Magawa C, Eaton-Fitch N, Thapaliya K, Marshall-Gradisnik S (May 2023). "Biomarkers for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS): a systematic review". BMC Medicine. 21 (1): 189. doi:10.1186/s12916-023-02893-9. PMC 10206551. PMID 37226227.
  80. ^ a b "Diagnosis of ME/CFS". 15 May 2019. Archived from the original on 28 July 2020. Retrieved 23 May 2020.
  81. ^ Bansal AS (July 2016). "Investigating unexplained fatigue in general practice with a particular focus on CFS/ME". BMC Family Practice. 17 (81): 81. doi:10.1186/s12875-016-0493-0. PMC 4950776. PMID 27436349.
  82. ^ Institute of Medicine (2015). "Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome - Redefining an Illness. Report for Clinicians" (PDF). Institute of Medicine. Archived (PDF) from the original on 8 March 2022. Retrieved 26 March 2022.
  83. ^ a b National Guideline Centre (UK) (2021). Identifying and diagnosing ME/CFS: Myalgic encephalomyelitis (or encephalopathy) / chronic fatigue syndrome: diagnosis and management: Evidence review D. NICE Evidence Reviews Collection. London: National Institute for Health and Care Excellence (NICE). ISBN 978-1-4731-4221-3. PMID 35438857.
  84. ^ a b Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A (December 1994). "The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group". Annals of Internal Medicine. 121 (12): 953–959. doi:10.7326/0003-4819-121-12-199412150-00009. PMID 7978722. S2CID 510735.
  85. ^ a b c Holmes GP, Kaplan JE, Gantz NM, Komaroff AL, Schonberger LB, Straus SE, et al. (March 1988). "Chronic fatigue syndrome: a working case definition". Annals of Internal Medicine. 108 (3): 387–389. doi:10.7326/0003-4819-108-3-387. PMID 2829679.
  86. ^ Guideline 53: Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy). London: National Institute for Health and Clinical Excellence. 2007. ISBN 978-1-84629-453-2. Archived from the original on 1 June 2014. Retrieved 3 September 2007.
  87. ^ Carruthers BM, Jain AK, De Meirleir KL, Peterson DL, Klimas NG, Lerner AM, et al. (4 December 2011). "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome". Journal of Chronic Fatigue Syndrome. 11 (1): 7–115. doi:10.1300/J092v11n01_02.
  88. ^ a b c Carruthers BM, van de Sande MI, De Meirleir KL, Klimas NG, Broderick G, Mitchell T, et al. (October 2011). "Myalgic encephalomyelitis: International Consensus Criteria". Journal of Internal Medicine. 270 (4): 327–338. doi:10.1111/j.1365-2796.2011.02428.x. PMC 3427890. PMID 21777306.
  89. ^ a b c d e f "Recommendations - Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management - Guidance". National Institute for Health and Care Excellence (NICE). 29 October 2021. Archived from the original on 29 December 2021. Retrieved 15 January 2022.
  90. ^ "Other Conditions for Evaluation". U.S. Centers for Disease Control and Prevention (CDC). 18 July 2018. Retrieved 22 September 2023.
  91. ^ a b c d e f g Baraniuk JN (January 2022). Myalgic encephalomyelitis (Chronic fatigue syndrome) (PDF). BMJ Best Practice. Retrieved 30 September 2023.
  92. ^ Nacul L, Authier FJ, Scheibenbogen C, Lorusso L, Helland IB, Martin JA, et al. (May 2021). "European Network on Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (EUROMENE): Expert Consensus on the Diagnosis, Service Provision, and Care of People with ME/CFS in Europe". Medicina. 57 (5): 510. doi:10.3390/medicina57050510. PMC 8161074. PMID 34069603.
  93. ^ Hakim A, De Wandele I, O'Callaghan C, Pocinki A, Rowe P (March 2017). "Chronic fatigue in Ehlers-Danlos syndrome-Hypermobile type". American Journal of Medical Genetics. Part C, Seminars in Medical Genetics. 175 (1): 175–180. doi:10.1002/ajmg.c.31542. PMID 28186393. Archived from the original on 11 December 2019. Retrieved 11 December 2019.
  94. ^ a b c Chou R, McDonagh M, Griffins J, Grusing S (2022). Management of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): An Updated Systematic Evidence Review (PDF). Centers for Disease Control and Prevention.
  95. ^ "Comorbid Conditions". U.S. Centers for Disease Control and Prevention (CDC). 12 July 2018. Archived from the original on 7 June 2020. Retrieved 29 May 2020.
  96. ^ a b Goudsmit EM, Nijs J, Jason LA, Wallman KE (19 December 2011). "Pacing as a strategy to improve energy management in myalgic encephalomyelitis/chronic fatigue syndrome: a consensus document". Disability and Rehabilitation. 34 (13): 1140–1147. doi:10.3109/09638288.2011.635746. PMID 22181560. S2CID 22457926. Archived from the original on 28 July 2020. Retrieved 23 May 2020.
  97. ^ Nielson WR, Jensen MP, Karsdorp PA, Vlaeyen JW (May 2013). "Activity pacing in chronic pain: concepts, evidence, and future directions". The Clinical Journal of Pain. 29 (5): 461–468. doi:10.1097/AJP.0b013e3182608561. PMID 23247005. S2CID 28709499.
  98. ^ Jason LA, Brown M, Brown A, Evans M, Flores S, Grant-Holler E, Sunnquist M (January 2013). "Energy Conservation/Envelope Theory Interventions to Help Patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome". Fatigue. 1 (1–2): 27–42. doi:10.1080/21641846.2012.733602. PMC 3596172. PMID 23504301.
  99. ^ a b O'connor K, Sunnquist M, Nicholson L, Jason LA, Newton JL, Strand EB (March 2019). "Energy envelope maintenance among patients with myalgic encephalomyelitis and chronic fatigue syndrome: Implications of limited energy reserves". Chronic Illness. 15 (1): 51–60. doi:10.1177/1742395317746470. PMC 5750135. PMID 29231037.
  100. ^ "ME Association Summary Review: Assessing PEM (Post-exertional Malaise)" (PDF). ME Association. 2019. Archived (PDF) from the original on 28 July 2020. Retrieved 23 May 2020.
  101. ^ Sanal-Hayes, Nilihan E. M.; Mclaughlin, Marie; Hayes, Lawrence D.; Mair, Jacqueline L.; Ormerod, Jane; Carless, David; Hilliard, Natalie; Meach, Rachel; Ingram, Joanne; Sculthorpe, Nicholas F. (2023). "A scoping review of 'Pacing' for management of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): lessons learned for the long COVID pandemic". Journal of Translational Medicine. 21 (1): 720. doi:10.1186/s12967-023-04587-5. ISSN 1479-5876. PMC 10576275. PMID 37838675.
  102. ^ Castro-Marrero J, Sáez-Francàs N, Santillo D, Alegre J (March 2017). "Treatment and management of chronic fatigue syndrome/myalgic encephalomyelitis: all roads lead to Rome". British Journal of Pharmacology. 174 (5): 345–369. doi:10.1111/bph.13702. PMC 5301046. PMID 28052319.
  103. ^ a b c Geraghty K, Jason L, Sunnquist M, Tuller D, Blease C, Adeniji C (23 April 2019). "The 'cognitive behavioural model' of chronic fatigue syndrome: Critique of a flawed model". Health Psychology Open. 6 (1): 2055102919838907. doi:10.1177/2055102919838907. PMC 6482658. PMID 31041108.
  104. ^ a b c Ahmed SA, Mewes JC, Vrijhoef H (February 2020). "Assessment of the scientific rigour of randomized controlled trials on the effectiveness of cognitive behavioural therapy and graded exercise therapy for patients with myalgic encephalomyelitis/chronic fatigue syndrome: A systematic review". Journal of Health Psychology. 25 (2): 240–255. doi:10.1177/1359105319847261. PMID 31072121. S2CID 149443976.
  105. ^ a b Agrawal S, Kandimalla ER (February 2019). "Chapter 14: Synthetic agonists of Toll-like receptors and therapeutic applications.". In Agrawal S, Gait MJ (eds.). Advances in Nucleic Acid Therapeutics. Royal Society of Chemistry. pp. 306–338 (310). ISBN 978-1-78801-732-9. Archived from the original on 14 May 2022. Retrieved 20 October 2021. 14.2: Agonists of TLR3
  106. ^ a b Michaeleen D (2 October 2017). "For People With Chronic Fatigue Syndrome, More Exercise Isn't Better".
  107. ^ Larun L, Brurberg KG, Odgaard-Jensen J, Price JR (October 2019). "Exercise therapy for chronic fatigue syndrome". The Cochrane Database of Systematic Reviews. 10 (10): CD003200. doi:10.1002/14651858.CD003200.pub8. PMC 6953363. PMID 31577366.
  108. ^ Richman S, Morris MC, Broderick G, Craddock TJ, Klimas NG, Fletcher MA (May 2019). "Pharmaceutical Interventions in Chronic Fatigue Syndrome: A Literature-based Commentary". Clinical Therapeutics. 41 (5): 798–805. doi:10.1016/j.clinthera.2019.02.011. PMC 6543846. PMID 30871727.
  109. ^ "FDA Response Letter Regarding Approval of Ampligen for ME/CFS". U.S. Food and Drug Administration (FDA). Archived from the original on 23 October 2016. Retrieved 12 June 2018.
  110. ^ Barclay L (5 February 2013). "FDA Nixes Rintatolimod for Chronic Fatigue Syndrome". Medscape. Archived from the original on 20 June 2015. Retrieved 18 January 2017.
  111. ^ a b c d "Prognosis". U.S. Centers for Disease Control and Prevention (CDC). 23 July 2019. Retrieved 15 July 2022.
  112. ^ a b c d "Recommendations". National Institute for Health and Care Excellence (NICE). 29 October 2021. Retrieved 15 July 2022.
  113. ^ Cairns R, Hotopf M (January 2005). "A systematic review describing the prognosis of chronic fatigue syndrome". Occupational Medicine. 55 (1): 20–31. doi:10.1093/occmed/kqi013. PMID 15699087.
  114. ^ "Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management". National Institute for Health and Care Excellence (NICE). 29 October 2021. Retrieved 8 March 2023.
  115. ^ "Products - Data Briefs - Number 488 - December 2023". www.cdc.gov. 8 December 2023. Retrieved 8 December 2023.
  116. ^ "Epidemiology". U.S. Centers for Disease Control and Prevention (CDC). 27 April 2021. Retrieved 16 July 2022.
  117. ^ a b c Acheson ED (April 1959). "The clinical syndrome variously called benign myalgic encephalomyelitis, Iceland disease and epidemic neuromyasthenia". The American Journal of Medicine. 26 (4): 569–595. CiteSeerX 10.1.1.534.4761. doi:10.1016/0002-9343(59)90280-3. PMID 13637100.
  118. ^ a b Parish JG (November 1978). "Early outbreaks of 'epidemic neuromyasthenia'". Postgraduate Medical Journal. 54 (637): 711–717. doi:10.1136/pgmj.54.637.711. PMC 2425322. PMID 370810.
  119. ^ a b Wojcik W, Armstrong D, Kanaan R (June 2011). "Chronic fatigue syndrome: labels, meanings and consequences". Journal of Psychosomatic Research. 70 (6): 500–504. doi:10.1016/j.jpsychores.2011.02.002. PMID 21624573.
  120. ^ "Outbreak at the royal free". The Lancet. 266 (6885): 351–352. 1955. doi:10.1016/s0140-6736(55)92344-8.
  121. ^ Price JL (April 1961). "Myalgic encephalomyelitis". Lancet. 1 (7180): 737–738. doi:10.1016/s0140-6736(61)92893-8. PMC 1836797. PMID 13737972.
  122. ^ International Classification of Diseases. Vol. I. World Health Organization. 1969. pp. 158, (vol 2, pp. 173).
  123. ^ Ramsay AM (1988). Myalgic encephalomyelitis and postviral fatigue states (Second ed.).
  124. ^ Ramsey, A.Melvin; David, Anthonys.; Wessely, Simon; Pelosi, Anthonyj.; Dowsett, E.G. (July 1988). "Myalgic encephalomyelitis, or what?". Lancet. 2 (8602): 100–101. doi:10.1016/s0140-6736(88)90028-1. PMID 2898668. S2CID 24860444.
  125. ^ Ramsay AM, Dowsett EG, Dadswell JV, Lyle WH, Parish JG (May 1977). "Icelandic disease (benign myalgic encephalomyelitis or Royal Free disease)". British Medical Journal. 1 (6072): 1350. doi:10.1136/bmj.1.6072.1350-a. PMC 1607215. PMID 861618.
  126. ^ Straus SE (1991). "History of chronic fatigue syndrome". Reviews of Infectious Diseases. 13 (Suppl. 1): S2–S7. doi:10.1093/clinids/13.supplement_1.s2. PMID 2020800.
  127. ^ "Press Briefing Transcripts". Centers for Disease Control and Prevention. 3 November 2006. Archived from the original on 15 October 2013. Retrieved 12 October 2013.
  128. ^ Shelokov A, Habel K, Verder E, Welsh W (August 1957). "Epidemic neuromyasthenia; an outbreak of poliomyelitislike illness in student nurses". The New England Journal of Medicine. 257 (8): 345–355. doi:10.1056/NEJM195708222570801. PMID 13464938.
  129. ^ Blattner RJ (October 1956). "Benign myalgic encephalomyelitis (Akureyri disease, Iceland disease)". The Journal of Pediatrics. 49 (4): 504–506. doi:10.1016/S0022-3476(56)80241-2. PMID 13358047.
  130. ^ Straus SE, ed. (1994). Chronic Fatigue Syndrome. New York, Basel, Hong Kong: Marcel Dekker Inc. p. 227. ISBN 978-0-8247-9187-2.
  131. ^ Aoki T, Usuda Y, Miyakoshi H, Tamura K, Herberman RB (1987). "Low natural killer syndrome: clinical and immunologic features". Natural Immunity and Cell Growth Regulation. 6 (3): 116–128. PMID 2442602.
  132. ^ Wessely S (October 1991). "History of postviral fatigue syndrome". British Medical Bulletin. 47 (4): 919–941. doi:10.1093/oxfordjournals.bmb.a072521. PMID 1794091. S2CID 12964461.
  133. ^ Ramsay AM (1986). Postviral Fatigue Syndrome. The saga of Royal Free disease. London: Gower. ISBN 978-0-906923-96-2.
  134. ^ Simpson LO (October 1991). "Myalgic encephalomyelitis". Journal of the Royal Society of Medicine. 84 (10): 633. PMC 1295578. PMID 1744860.
  135. ^ a b Bhatia S, Jason LA (24 February 2023). "Using Data Mining and Time Series to Investigate ME and CFS Naming Preferences". Journal of Disability Policy Studies: 104420732311540. doi:10.1177/10442073231154027. ISSN 1044-2073. S2CID 257198201.
  136. ^ Jason LA, Johnson M (2 April 2020). "Solving the ME/CFS criteria and name conundrum: the aftermath of IOM". Fatigue: Biomedicine, Health & Behavior. 8 (2): 97–107. doi:10.1080/21641846.2020.1757809. ISSN 2164-1846. S2CID 219011696.
  137. ^ Jason LA, Mirin AA (January 2021). "Updating the National Academy of Medicine ME/CFS prevalence and economic impact figures to account for population growth and inflation" (PDF). Fatigue: Biomedicine, Health & Behavior. 9 (1): 9–13. doi:10.1080/21641846.2021.1878716. ISSN 2164-1846. S2CID 233745601.
  138. ^ a b "ME/Chronic Fatigue Syndrome Awareness Day". Centers for Disease Control and Prevention. 5 May 2023. Retrieved 6 December 2023.
  139. ^ Lee N. "Dr. Nancy Lee on International Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Awareness Day". US Department of Health & Human Services. Archived from the original on 8 July 2012. Retrieved 12 October 2013.
  140. ^ Young DA (23 December 1995). "Florence Nightingale's fever". BMJ. 311 (7021): 1697–1700. doi:10.1136/bmj.311.7021.1697. PMC 2539100. PMID 8541764.
  141. ^ Hooge J (1992). "Chronic fatigue syndrome: cause, controversy and care". British Journal of Nursing. 1 (9): 440–41, 443, 445–46. doi:10.12968/bjon.1992.1.9.440. PMID 1446147.
  142. ^ a b Sharpe M (September 1996). "Chronic fatigue syndrome". The Psychiatric Clinics of North America. 19 (3): 549–573. doi:10.1016/S0193-953X(05)70305-1. PMID 8856816.
  143. ^ Denz-Penhey H, Murdoch JC (April 1993). "General practitioners acceptance of the validity of chronic fatigue syndrome as a diagnosis". The New Zealand Medical Journal. 106 (953): 122–124. PMID 8474729.
  144. ^ Greenlee JE, Rose JW (2000). "Controversies in neurological infectious diseases". Seminars in Neurology. 20 (3): 375–386. doi:10.1055/s-2000-9429. PMID 11051301. S2CID 27175304.
  145. ^ a b c d Pheby DF, Araja D, Berkis U, Brenna E, Cullinan J, de Korwin JD, et al. (December 2020). "A Literature Review of GP Knowledge and Understanding of ME/CFS: A Report from the Socioeconomic Working Group of the European Network on ME/CFS (EUROMENE)". Medicina. 57 (1): 7. doi:10.3390/medicina57010007. PMC 7823627. PMID 33374291.
  146. ^ a b c Davis HE, McCorkell L, Vogel JM, Topol EJ (March 2023). "Long COVID: major findings, mechanisms and recommendations". Nature Reviews. Microbiology. 21 (3): 133–146. doi:10.1038/s41579-022-00846-2. PMC 9839201. PMID 36639608.
  147. ^ Bowen J, Pheby D, Charlett A, McNulty C (August 2005). "Chronic Fatigue Syndrome: a survey of GPs' attitudes and knowledge". Family Practice. 22 (4): 389–393. doi:10.1093/fampra/cmi019. PMID 15805128.
  148. ^ Dumit J (February 2006). "Illnesses you have to fight to get: facts as forces in uncertain, emergent illnesses". Social Science & Medicine. 62 (3): 577–590. doi:10.1016/j.socscimed.2005.06.018. PMID 16085344.
  149. ^ a b Lombardi VC, Ruscetti FW, Das Gupta J, Pfost MA, Hagen KS, Peterson DL, et al. (October 2009). "Detection of an infectious retrovirus, XMRV, in blood cells of patients with chronic fatigue syndrome". Science. 326 (5952): 585–589. Bibcode:2009Sci...326..585L. doi:10.1126/science.1179052. PMC 3073172. PMID 19815723. (Retracted, see doi:10.1126/science.334.6063.1636-a)
  150. ^ "No blood from chronic fatigue donors: agency". CBC. 7 April 2010. Archived from the original on 11 April 2010. Retrieved 25 June 2010.
  151. ^ Atkinson K (21 April 2010). "Chronic Fatigue Set To Disqualify Blood Donors". Voxy.co.nz. Archived from the original on 24 April 2010. Retrieved 25 June 2010.
  152. ^ "Blood Service updates CFS donor policy". Australian Red Cross Blood Service. Archived from the original on 14 October 2013. Retrieved 7 July 2013.
  153. ^ "Recommendation on Chronic Fatigue Syndrome and Blood Donation". American Association of Blood Banks. 18 June 2010. Archived from the original on 25 June 2010. Retrieved 25 June 2010.
  154. ^ NHS Blood and Transplant (5 November 2010). "ME/CFS sufferers permanently deferred from giving blood". Archived from the original on 28 November 2015. Retrieved 9 October 2011.
  155. ^ NHS Blood and Transplant. "Chronic Fatigue Syndrome". Archived from the original on 11 February 2015. Retrieved 11 February 2015.
  156. ^ Hempel S, Chambers D, Bagnall AM, Forbes C (July 2008). "Risk factors for chronic fatigue syndrome/myalgic encephalomyelitis: a systematic scoping review of multiple predictor studies". Psychological Medicine. 38 (7): 915–926. doi:10.1017/S0033291707001602. PMID 17892624. S2CID 20277129.
  157. ^ Tuller D (30 May 2008). "Chronic Fatigue Syndrome No Longer Seen as 'Yuppie Flu'". The New York Times. Archived from the original on 17 March 2015. Retrieved 29 June 2015.
  158. ^ Wallace PG (October 1991). "Post-viral fatigue syndrome. Epidemiology: a critical review". British Medical Bulletin. 47 (4): 942–951. doi:10.1093/oxfordjournals.bmb.a072522. PMID 1794092.
  159. ^ Mounstephen A, Sharpe M (May 1997). "Chronic fatigue syndrome and occupational health". Occupational Medicine. 47 (4): 217–227. doi:10.1093/occmed/47.4.217. PMID 9231495.
  160. ^ Jason LA, Richman JA, Friedberg F, Wagner L, Taylor R, Jordan KM (September 1997). "Politics, science, and the emergence of a new disease. The case of chronic fatigue syndrome". The American Psychologist. 52 (9): 973–983. doi:10.1037/0003-066X.52.9.973. PMID 9301342.
  161. ^ McManimen, Stephanie L.; McClellan, Damani; Stoothoff, Jamie; Jason, Leonard A. (November 2018). "Effects of unsupportive social interactions, stigma, and symptoms on patients with myalgic encephalomyelitis and chronic fatigue syndrome". Journal of Community Psychology. 46 (8): 959–971. doi:10.1002/jcop.21984.
  162. ^ McEvedy CP, Beard AW (January 1970). "Concept of benign myalgic encephalomyelitis". British Medical Journal. 1 (5687): 11–15. doi:10.1136/bmj.1.5687.11. PMC 1700895. PMID 5411596.
  163. ^ The Medical Staff Of The Royal Free Hospital (October 1957). "AN OUTBREAK of encephalomyelitis in the Royal Free Hospital Group, London, in 1955". British Medical Journal. 2 (5050): 895–904. doi:10.1136/bmj.2.5050.895. PMC 1962472. PMID 13472002.
  164. ^ Evengård B, Schacterle RS, Komaroff AL (November 1999). "Chronic fatigue syndrome: new insights and old ignorance". Journal of Internal Medicine. 246 (5): 455–469. doi:10.1046/j.1365-2796.1999.00513.x. PMID 10583715. S2CID 34123925.
  165. ^ a b c Speight N (2013). "Myalgic encephalomyelitis/chronic fatigue syndrome: Review of history, clinical features, and controversies". Saudi Journal of Medicine & Medical Sciences. 1 (1): 11–13. doi:10.4103/1658-631x.112905.
  166. ^ Cowley G, Hager M, Joseph N (12 November 1990), "Chronic Fatigue Syndrome", Newsweek: Cover Story, archived from the original on 28 July 2020, retrieved 24 July 2020
  167. ^ Frumkin H, Packard RM, Brown P, Berkelman RL (2004). Emerging illnesses and society: negotiating the public health agenda. Baltimore: Johns Hopkins University Press. p. 156. ISBN 978-0-8018-7942-5.
  168. ^ Erlwein O, Kaye S, McClure MO, Weber J, Wills G, Collier D, et al. (January 2010). Nixon DF (ed.). "Failure to detect the novel retrovirus XMRV in chronic fatigue syndrome". PLOS ONE. 5 (1): e8519. Bibcode:2010PLoSO...5.8519E. doi:10.1371/journal.pone.0008519. PMC 2795199. PMID 20066031.
  169. ^ Groom HC, Boucherit VC, Makinson K, Randal E, Baptista S, Hagan S, et al. (February 2010). "Absence of xenotropic murine leukaemia virus-related virus in UK patients with chronic fatigue syndrome". Retrovirology. 7 (1): 10. doi:10.1186/1742-4690-7-10. PMC 2839973. PMID 20156349.
  170. ^ van Kuppeveld FJ, de Jong AS, Lanke KH, Verhaegh GW, Melchers WJ, Swanink CM, et al. (February 2010). "Prevalence of xenotropic murine leukaemia virus-related virus in patients with chronic fatigue syndrome in the Netherlands: retrospective analysis of samples from an established cohort". BMJ. 340: c1018. doi:10.1136/bmj.c1018. PMC 2829122. PMID 20185493.
  171. ^ Alberts B (December 2011). "Retraction". Science. 334 (6063): 1636. Bibcode:2011Sci...334.1636A. doi:10.1126/science.334.6063.1636-a. PMID 22194552.
  172. ^ Lo SC, Pripuzova N, Li B, Komaroff AL, Hung GC, Wang R, Alter HJ (January 2012). "Retraction for Lo et al., Detection of MLV-related virus gene sequences in blood of patients with chronic fatigue syndrome and healthy blood donors". Proceedings of the National Academy of Sciences of the United States of America. 109 (1): 346. Bibcode:2012PNAS..109..346.. doi:10.1073/pnas.1119641109. PMC 3252929. PMID 22203980.
  173. ^ a b Radford G, Chowdhury S (2016). "ME/CFS Research Funding - An Overview Of Activity By Major Instutional [sic] Funders Included On The Dimensions Database" (PDF). UK CFS/ME Research Collaborative and ÜberResearch.
  174. ^ Scheibenbogen C, Freitag H, Blanco J, Capelli E, Lacerda E, Authier J, et al. (July 2017). "The European ME/CFS Biomarker Landscape project: an initiative of the European network EUROMENE". Journal of Translational Medicine. 15 (1): 162. doi:10.1186/s12967-017-1263-z. PMC 5530475. PMID 28747192.
  175. ^ a b c d Toogood PL, Clauw DJ, Phadke S, Hoffman D (March 2021). "Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS): Where will the drugs come from?". Pharmacological Research. 165: 105465. doi:10.1016/j.phrs.2021.105465. PMID 33529750. S2CID 231787959.
  176. ^ "Grants & Funding". National Institutes of Health (NIH). Retrieved 22 November 2023.
  177. ^ a b Mirin AA (July 2021). "Gender Disparity in the Funding of Diseases by the U.S. National Institutes of Health". Journal of Women's Health. 30 (7): 956–963. doi:10.1089/jwh.2020.8682. PMC 8290307. PMID 33232627.
  178. ^ Mirin AA, Dimmock ME, Jason LA (2020). Mooney A (ed.). "Research update: The relation between ME/CFS disease burden and research funding in the USA". Work. 66 (2): 277–282. doi:10.3233/WOR-203173. PMID 32568148. S2CID 219974997.
  179. ^ "Golden Girls, Chronic Fatigue Syndrome, and the Legacies of Hysteria". Nursing Clio. 25 September 2018. Archived from the original on 28 July 2020. Retrieved 14 November 2019.
  180. ^ Cain P (2007). "Ann Bannon". Leading the parade: Conversations with America's most influential lesbians and gay men. Scarecrow Press, Inc. pp. 155–63. ISBN 978-0-8108-5913-5.
  181. ^ Hylton WS (18 December 2014). "The Unbreakable Laura Hillenbrand". The New York Times. ISSN 0362-4331. Archived from the original on 4 March 2020. Retrieved 27 June 2020.
  182. ^ Parker-Pope T (4 February 2011). "An Author Escapes From Chronic Fatigue Syndrome". Well. Archived from the original on 4 July 2020. Retrieved 27 June 2020.
  183. ^ Marshall-Gradisnik S, Eaton-Fitch N (September 2022). "Understanding myalgic encephalomyelitis". Science. 377 (6611): 1150–1151. Bibcode:2022Sci...377.1150M. doi:10.1126/science.abo1261. hdl:10072/420658. PMID 36074854. S2CID 252159772.
  184. ^ a b c d e f Missailidis D, Annesley SJ, Fisher PR (July 2019). "Pathological Mechanisms Underlying Myalgic Encephalomyelitis/Chronic Fatigue Syndrome". Diagnostics. 9 (3): 80. doi:10.3390/diagnostics9030080. PMC 6787592. PMID 31330791.
  185. ^ Dibble JJ, McGrath SJ, Ponting CP (September 2020). "Genetic risk factors of ME/CFS: a critical review". Human Molecular Genetics. 29 (R1): R117–R124. doi:10.1093/hmg/ddaa169. PMC 7530519. PMID 32744306.
  186. ^ "Experts launch world's largest genetic study of ME". BBC News. 12 September 2022. Retrieved 20 January 2023.
  187. ^ a b c Tate WP, Walker MO, Peppercorn K, Blair AL, Edgar CD (March 2023). "Towards a Better Understanding of the Complexities of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome and Long COVID". International Journal of Molecular Sciences. 24 (6): 5124. doi:10.3390/ijms24065124. PMC 10048882. PMID 36982194.
Retrieved from "https://en.wikipedia.org/w/index.php?title=Myalgic_encephalomyelitis/chronic_fatigue_syndrome&oldid=1192484044"