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doi: 10.3389/fphys.2013.00181 Migraine in gulf war illness and chronic fatigue syndrome: prevalen... more doi: 10.3389/fphys.2013.00181 Migraine in gulf war illness and chronic fatigue syndrome: prevalence, potential mechanisms, and evaluation

World Allergy Organization Journal, 2012

Background Medical questionnaires are important for assessing allergy patients. However, current ... more Background Medical questionnaires are important for assessing allergy patients. However, current methods of administering questionnaires are cumbersome, expensive, and laborious to accurately administer, track and score. eZhengtricity is a simple Google Documents based workflow, coupled with customized Excel formulas, that allow researchers to create, collect and score confidential health questionnaires that are globally accessible, with minimal setup time and maintenance. Methods eZhengtricity utilizes a Google Documents account as a platform to create online questionnaires. Google automatically hosts the online questionnaire with a unique URL that can be provided to patients. The researcher provides patients with a unique study ID that is used to submit questionnaire responses. By using a unique study ID, researchers ensure confidentially of questionnaire data. Patient questionnaire responses are instantly submitted online to a secured “Cloud” database. In the Cloud database, the data is automatically sorted, scaled and scored by custom Excel formulas. Researchers can instantly access the database and download results in a variety of formats including PDF and XLS for further analysis using the researcher's statistical software of choice. Results eZhengtricity provided questionnaire scores from submitted questionnaires instantly, while paper versions required manual double entry and manual sorting of patient data for analysis. Better overall quality of patient responses was obtained with eZhengtricity compared to paper questionnaires. Submitted responses to eZhengtricity had 100 percent completion while submitted paper responses had incomplete responses. Patient compliance for eZhengtricity was comparable to paper questionnaires. eZhengtricity also allowed monitoring of patient's progress on completing questionnaires. Conclusions The flexibility and robustness of eZhengtricity complement longitudinal and cross-sectional studies. Compared to paper questionnaires, eZhengtricity is a cost effective, logistically easy, and superior way to administer confidential questionnaires.

Global Journal of Health Science, 2012

Chronic Fatigue Syndrome (CFS) subjects have many systemic complaints including shortness of brea... more Chronic Fatigue Syndrome (CFS) subjects have many systemic complaints including shortness of breath. Dyspnea was compared in two CFS and control cohorts to characterize pathophysiology. Cohort 1 of 257 CFS and 456 control subjects were compared using the Medical Research Council chronic Dyspnea Scale (MRC Score; range 0-5). Cohort 2 of 106 CFS and 90 controls answered a Dyspnea Severity Score (range 0-20) adapted from the MRC Score. Subsets of both cohorts completed CFS Severity Scores, fatigue, and other questionnaires. A subset had pulmonary function and total lung capacity measurements. Results show MRC Scores were equivalent between sexes in Cohort 1 CFS (1.92 [1.72-2.16]; mean [95% C.I.]) and controls (0.31 [0.23-0.39]; p<0.0001). Receiver-operator curves identified 2 as the threshold for positive MRC Scores in Cohort 1. This indicated 54% of CFS, but only 3% of controls, had significant dyspnea. In Cohort 2, Dyspnea Score threshold of 4 indicated shortness of breath in 67% of CFS and 23% of controls. Cohort 2 Dyspnea Scores were higher for CFS (7.80 [6.60-9.00]) than controls (2.40 [1.60-3.20]; p<0.0001). CFS had significantly worse fatigue and other complaints compared to controls. Pulmonary function was normal in CFS, but Borg scores and sensations of chest pain and dizziness were significantly greater during testing than controls. General linear model of Cohort 2 CFS responses linked Dyspnea with rapid heart rate, chest pain and dizziness. In conclusion, sensory hypersensitivity without airflow limitation contributed to dyspnea in CFS. Correlates of dyspnea in controls were distinct from CFS suggesting different mechanisms.

Frontiers in Physiology, 2013

To assess the prevalence of headache subtypes in Gulf War Illness (GWI) and Chronic Fatigue Syndr... more To assess the prevalence of headache subtypes in Gulf War Illness (GWI) and Chronic Fatigue Syndrome (CFS) compared to controls. Background: Approximately, 25% of the military personnel who served in the 1990-1991 Persian Gulf War have developed GWI. Symptoms of GWI and CFS have considerable overlap, including headache complaints. Migraines are reported in CFS. The type and prevalence of headaches in GWI have not been adequately assessed. Methods: 50 GWI, 39 CFS and 45 controls had structured headache evaluations based on the 2004 International Headache Society criteria. All subjects had history and physical examinations, fatigue and symptom related questionnaires, measurements of systemic hyperalgesia (dolorimetry), and assessments for exclusionary conditions. Results: Migraines were detected in 64% of GWI (odds ratio = 11.6 [4.1-32.5]) (mean [±95% CI]) and 82% of CFS subjects (odds ratio = 22.5 [7.8-64.8]) compared to only 13% of controls. There was a predominance of females in the CFS compared to GWI and controls. However, migraine status was independent of gender in GWI and CFS groups (x 2 = 2.7; P = 0.101). Measures of fatigue, pain, and other ancillary criteria were comparable between GWI and CFS subjects with and without headache. Conclusion: The high prevalence of migraine in CFS was confirmed and extended to GWI subjects. GWI and CFS may share dysfunctional central pathophysiological pathways that contribute to migraine and subjective symptoms. The high migraine prevalence warrants the inclusion of a structured headache evaluation in GWI and CFS subjects, and treatment when present.

World Allergy Organization Journal, 2012

obese. We also found a decrease in FEV1 comparing the 3 groups with a P , .011 morbid versus eutr... more obese. We also found a decrease in FEV1 comparing the 3 groups with a P , .011 morbid versus eutrophic and P , .049 morbid versus obese. Conclusions: Our results confirm the findings of others, who have shown that lung volumes especially FRC and ERV decrease as body weight increases. Obese patients have a combination of mechanical and inflammatory effects that result in pulmonary disability.

Journal of Allergy and Clinical Immunology, 2009

BMC Neurology, 2011

Background Headaches are more frequent in Chronic Fatigue Syndrome (CFS) than healthy control (HC... more Background Headaches are more frequent in Chronic Fatigue Syndrome (CFS) than healthy control (HC) subjects. The 2004 International Headache Society (IHS) criteria were used to define CFS headache phenotypes. Methods Subjects in Cohort 1 (HC = 368; CFS = 203) completed questionnaires about many diverse symptoms by giving nominal (yes/no) answers. Cohort 2 (HC = 21; CFS = 67) had more focused evaluations. They scored symptom severities on 0 to 4 anchored ordinal scales, and had structured headache evaluations. All subjects had history and physical examinations; assessments for exclusion criteria; questionnaires about CFS related symptoms (0 to 4 scale), Multidimensional Fatigue Inventory (MFI) and Medical Outcome Survey Short Form 36 (MOS SF-36). Results Demographics, trends for the number of diffuse "functional" symptoms present, and severity of CFS case designation criteria symptoms were equivalent between CFS subjects in Cohorts 1 and 2. HC had significantly fewer sympto...

American journal of translational research, 2013

Chronic Fatigue Syndrome case designation criteria are scored as physicians' subjective, nomi... more Chronic Fatigue Syndrome case designation criteria are scored as physicians' subjective, nominal interpretations of patient fatigue, pain (headaches, myalgia, arthralgia, sore throat and lymph nodes), cognitive dysfunction, sleep and exertional exhaustion. Subjects self-reported symptoms using an anchored ordinal scale of 0 (no symptom), 1 (trivial complaints), 2 (mild), 3 (moderate), and 4 (severe). Fatigue of 3 or 4 distinguished "Fatigued" from "Not…

World Allergy Organization Journal, 2012

All patients with asthma underwent immediate cutaneous testing including prick (epicutaneous) wit... more All patients with asthma underwent immediate cutaneous testing including prick (epicutaneous) with a mix of Aspergillus species and if negative, intradermal at 1000 PNU/mL, Aspergillus fumigatus (Af). Sera were analyzed for total IgE (elevated is 417kU/L)byPhadiaImmuno−Cap,anti−AfIgEandanti−AfIgG(ABPArange417 kU/L) by Phadia Immuno-Cap, anti-Af IgE and anti-Af IgG (ABPA range 417kU/L)byPhadiaImmuno−Cap,anti−AfIgEandanti−AfIgG(ABPArange 2.0) ELISA, and precipitating antibodies. HRCT of the lungs was ordered next if serology was positive (diagnostic criteria for ABPA required total IgE $ 417 kU/L and both anti-Af IgE and IgG $ 2.0 compared to sera from skin test 1 patients with asthma without ABPA). To avoid bias from patients examined by the author, data were compared using screening from 5 other faculty in the same clinic. Results: From 2000 to 2010, 864 skin test 1 patients underwent serologic testing for ABPA from which 81 (9.4%) were diagnostic for ABPA, and in this group, precipitins were positive in 42/81. To address referral bias in screened patients of the author, diagnostic criteria were positive in 49/208 (23.5%) patients of the author versus 32/656 (4.8%) of other allergy-immunology faculty. In addition, some 74/884 (8.6%) patients had total IgE $ 417 kU/L and either anti-Af IgE or IgG $ 2.0, implying an overall at risk for ABPA population of 155/864 (17.9%). The highest total IgE recorded in a non-ABPA patient with asthma was 192,100 kU/L. Conclusions: Using total IgE and ELISA determinations to discriminate ABPA from skin test 1 asthma sera, 9.4% of patients had diagnostic evidence for APBA. Using data from faculty, presumably with less referral bias than the author, results in 4.8% patients with classic diagnostic criteria. This rate conservatively translates into a minimum of approximately 1.2% of patients with persistent asthma having APBA in the upper Midwestern US. The combination of elevated total IgE and precipitins but not elevated anti-Af IgE or IgG in this population has little/no value in diagnosis.

Current Allergy and Asthma Reports, Apr 30, 2010

The concept of a sinus headache is problematic from neurology, allergology, and rhinology perspec... more The concept of a sinus headache is problematic from neurology, allergology, and rhinology perspectives. It may be considered the final neurological diagnosis of exclusion when criteria for other craniofacial pain syndromes are not met. The International Headache Society definition implicates the presence of acute sinusitis, but this requirement is often not met in practice or with a patient's perception of the term. Otorhinolaryngologists have a similar exasperation with this cephalgia but tend to attribute idiopathic, nonallergic rhinopathy as the cause. Allergists often see patients who claim to have a sinus headache but instead have perennial allergic rhinitis or nonallergic rhinitis. A fresh perspective is required to determine the characteristics, differential diagnosis, and veracity of the sinus headache. We recommend using the term with caution only if the clinical picture meets the criteria for acute sinusitisinduced headache.

doi: 10.3389/fphys.2013.00181 Migraine in gulf war illness and chronic fatigue syndrome: prevalen... more doi: 10.3389/fphys.2013.00181 Migraine in gulf war illness and chronic fatigue syndrome: prevalence, potential mechanisms, and evaluation

World Allergy Organization Journal, 2012

Background Medical questionnaires are important for assessing allergy patients. However, current ... more Background Medical questionnaires are important for assessing allergy patients. However, current methods of administering questionnaires are cumbersome, expensive, and laborious to accurately administer, track and score. eZhengtricity is a simple Google Documents based workflow, coupled with customized Excel formulas, that allow researchers to create, collect and score confidential health questionnaires that are globally accessible, with minimal setup time and maintenance. Methods eZhengtricity utilizes a Google Documents account as a platform to create online questionnaires. Google automatically hosts the online questionnaire with a unique URL that can be provided to patients. The researcher provides patients with a unique study ID that is used to submit questionnaire responses. By using a unique study ID, researchers ensure confidentially of questionnaire data. Patient questionnaire responses are instantly submitted online to a secured “Cloud” database. In the Cloud database, the data is automatically sorted, scaled and scored by custom Excel formulas. Researchers can instantly access the database and download results in a variety of formats including PDF and XLS for further analysis using the researcher's statistical software of choice. Results eZhengtricity provided questionnaire scores from submitted questionnaires instantly, while paper versions required manual double entry and manual sorting of patient data for analysis. Better overall quality of patient responses was obtained with eZhengtricity compared to paper questionnaires. Submitted responses to eZhengtricity had 100 percent completion while submitted paper responses had incomplete responses. Patient compliance for eZhengtricity was comparable to paper questionnaires. eZhengtricity also allowed monitoring of patient's progress on completing questionnaires. Conclusions The flexibility and robustness of eZhengtricity complement longitudinal and cross-sectional studies. Compared to paper questionnaires, eZhengtricity is a cost effective, logistically easy, and superior way to administer confidential questionnaires.

Global Journal of Health Science, 2012

Chronic Fatigue Syndrome (CFS) subjects have many systemic complaints including shortness of brea... more Chronic Fatigue Syndrome (CFS) subjects have many systemic complaints including shortness of breath. Dyspnea was compared in two CFS and control cohorts to characterize pathophysiology. Cohort 1 of 257 CFS and 456 control subjects were compared using the Medical Research Council chronic Dyspnea Scale (MRC Score; range 0-5). Cohort 2 of 106 CFS and 90 controls answered a Dyspnea Severity Score (range 0-20) adapted from the MRC Score. Subsets of both cohorts completed CFS Severity Scores, fatigue, and other questionnaires. A subset had pulmonary function and total lung capacity measurements. Results show MRC Scores were equivalent between sexes in Cohort 1 CFS (1.92 [1.72-2.16]; mean [95% C.I.]) and controls (0.31 [0.23-0.39]; p<0.0001). Receiver-operator curves identified 2 as the threshold for positive MRC Scores in Cohort 1. This indicated 54% of CFS, but only 3% of controls, had significant dyspnea. In Cohort 2, Dyspnea Score threshold of 4 indicated shortness of breath in 67% of CFS and 23% of controls. Cohort 2 Dyspnea Scores were higher for CFS (7.80 [6.60-9.00]) than controls (2.40 [1.60-3.20]; p<0.0001). CFS had significantly worse fatigue and other complaints compared to controls. Pulmonary function was normal in CFS, but Borg scores and sensations of chest pain and dizziness were significantly greater during testing than controls. General linear model of Cohort 2 CFS responses linked Dyspnea with rapid heart rate, chest pain and dizziness. In conclusion, sensory hypersensitivity without airflow limitation contributed to dyspnea in CFS. Correlates of dyspnea in controls were distinct from CFS suggesting different mechanisms.

Frontiers in Physiology, 2013

To assess the prevalence of headache subtypes in Gulf War Illness (GWI) and Chronic Fatigue Syndr... more To assess the prevalence of headache subtypes in Gulf War Illness (GWI) and Chronic Fatigue Syndrome (CFS) compared to controls. Background: Approximately, 25% of the military personnel who served in the 1990-1991 Persian Gulf War have developed GWI. Symptoms of GWI and CFS have considerable overlap, including headache complaints. Migraines are reported in CFS. The type and prevalence of headaches in GWI have not been adequately assessed. Methods: 50 GWI, 39 CFS and 45 controls had structured headache evaluations based on the 2004 International Headache Society criteria. All subjects had history and physical examinations, fatigue and symptom related questionnaires, measurements of systemic hyperalgesia (dolorimetry), and assessments for exclusionary conditions. Results: Migraines were detected in 64% of GWI (odds ratio = 11.6 [4.1-32.5]) (mean [±95% CI]) and 82% of CFS subjects (odds ratio = 22.5 [7.8-64.8]) compared to only 13% of controls. There was a predominance of females in the CFS compared to GWI and controls. However, migraine status was independent of gender in GWI and CFS groups (x 2 = 2.7; P = 0.101). Measures of fatigue, pain, and other ancillary criteria were comparable between GWI and CFS subjects with and without headache. Conclusion: The high prevalence of migraine in CFS was confirmed and extended to GWI subjects. GWI and CFS may share dysfunctional central pathophysiological pathways that contribute to migraine and subjective symptoms. The high migraine prevalence warrants the inclusion of a structured headache evaluation in GWI and CFS subjects, and treatment when present.

World Allergy Organization Journal, 2012

obese. We also found a decrease in FEV1 comparing the 3 groups with a P , .011 morbid versus eutr... more obese. We also found a decrease in FEV1 comparing the 3 groups with a P , .011 morbid versus eutrophic and P , .049 morbid versus obese. Conclusions: Our results confirm the findings of others, who have shown that lung volumes especially FRC and ERV decrease as body weight increases. Obese patients have a combination of mechanical and inflammatory effects that result in pulmonary disability.

Journal of Allergy and Clinical Immunology, 2009

BMC Neurology, 2011

Background Headaches are more frequent in Chronic Fatigue Syndrome (CFS) than healthy control (HC... more Background Headaches are more frequent in Chronic Fatigue Syndrome (CFS) than healthy control (HC) subjects. The 2004 International Headache Society (IHS) criteria were used to define CFS headache phenotypes. Methods Subjects in Cohort 1 (HC = 368; CFS = 203) completed questionnaires about many diverse symptoms by giving nominal (yes/no) answers. Cohort 2 (HC = 21; CFS = 67) had more focused evaluations. They scored symptom severities on 0 to 4 anchored ordinal scales, and had structured headache evaluations. All subjects had history and physical examinations; assessments for exclusion criteria; questionnaires about CFS related symptoms (0 to 4 scale), Multidimensional Fatigue Inventory (MFI) and Medical Outcome Survey Short Form 36 (MOS SF-36). Results Demographics, trends for the number of diffuse "functional" symptoms present, and severity of CFS case designation criteria symptoms were equivalent between CFS subjects in Cohorts 1 and 2. HC had significantly fewer sympto...

American journal of translational research, 2013

Chronic Fatigue Syndrome case designation criteria are scored as physicians' subjective, nomi... more Chronic Fatigue Syndrome case designation criteria are scored as physicians' subjective, nominal interpretations of patient fatigue, pain (headaches, myalgia, arthralgia, sore throat and lymph nodes), cognitive dysfunction, sleep and exertional exhaustion. Subjects self-reported symptoms using an anchored ordinal scale of 0 (no symptom), 1 (trivial complaints), 2 (mild), 3 (moderate), and 4 (severe). Fatigue of 3 or 4 distinguished "Fatigued" from "Not…

World Allergy Organization Journal, 2012

All patients with asthma underwent immediate cutaneous testing including prick (epicutaneous) wit... more All patients with asthma underwent immediate cutaneous testing including prick (epicutaneous) with a mix of Aspergillus species and if negative, intradermal at 1000 PNU/mL, Aspergillus fumigatus (Af). Sera were analyzed for total IgE (elevated is 417kU/L)byPhadiaImmuno−Cap,anti−AfIgEandanti−AfIgG(ABPArange417 kU/L) by Phadia Immuno-Cap, anti-Af IgE and anti-Af IgG (ABPA range 417kU/L)byPhadiaImmuno−Cap,anti−AfIgEandanti−AfIgG(ABPArange 2.0) ELISA, and precipitating antibodies. HRCT of the lungs was ordered next if serology was positive (diagnostic criteria for ABPA required total IgE $ 417 kU/L and both anti-Af IgE and IgG $ 2.0 compared to sera from skin test 1 patients with asthma without ABPA). To avoid bias from patients examined by the author, data were compared using screening from 5 other faculty in the same clinic. Results: From 2000 to 2010, 864 skin test 1 patients underwent serologic testing for ABPA from which 81 (9.4%) were diagnostic for ABPA, and in this group, precipitins were positive in 42/81. To address referral bias in screened patients of the author, diagnostic criteria were positive in 49/208 (23.5%) patients of the author versus 32/656 (4.8%) of other allergy-immunology faculty. In addition, some 74/884 (8.6%) patients had total IgE $ 417 kU/L and either anti-Af IgE or IgG $ 2.0, implying an overall at risk for ABPA population of 155/864 (17.9%). The highest total IgE recorded in a non-ABPA patient with asthma was 192,100 kU/L. Conclusions: Using total IgE and ELISA determinations to discriminate ABPA from skin test 1 asthma sera, 9.4% of patients had diagnostic evidence for APBA. Using data from faculty, presumably with less referral bias than the author, results in 4.8% patients with classic diagnostic criteria. This rate conservatively translates into a minimum of approximately 1.2% of patients with persistent asthma having APBA in the upper Midwestern US. The combination of elevated total IgE and precipitins but not elevated anti-Af IgE or IgG in this population has little/no value in diagnosis.

Current Allergy and Asthma Reports, Apr 30, 2010

The concept of a sinus headache is problematic from neurology, allergology, and rhinology perspec... more The concept of a sinus headache is problematic from neurology, allergology, and rhinology perspectives. It may be considered the final neurological diagnosis of exclusion when criteria for other craniofacial pain syndromes are not met. The International Headache Society definition implicates the presence of acute sinusitis, but this requirement is often not met in practice or with a patient's perception of the term. Otorhinolaryngologists have a similar exasperation with this cephalgia but tend to attribute idiopathic, nonallergic rhinopathy as the cause. Allergists often see patients who claim to have a sinus headache but instead have perennial allergic rhinitis or nonallergic rhinitis. A fresh perspective is required to determine the characteristics, differential diagnosis, and veracity of the sinus headache. We recommend using the term with caution only if the clinical picture meets the criteria for acute sinusitisinduced headache.