Multi-analyte profiling and pathway analysis of plasma for proteins associated with cancer-related fatigue syndrome in disease-free breast cancer patients after primary treatment

CONTEXT

A significant number of women treated for breast cancer develop long-term fatigue afterwards. Previous research has suggested that fatigue may be due to a prolonged inflammatory response. However, there are conflicting results and the exact nature of the disturbance remains unclear.

OBJECTIVES

To identify inflammatory markers associated with fatigue.

METHODS

We recruited women from a breast cancer follow-up clinic and categorised them on the basis of a diagnostic interview as to whether they met the criteria for cancer-related fatigue syndrome (cases) or not (controls). We took plasma samples from each participant to analyse subsequently using a panel of 88 biological markers.

RESULTS

90 samples were analysed in total (45 cases and 45 controls). A factorial analysis of variance (using age as a fixed factor) demonstrated a number of differences in inflammatory cytokines. There were 28 significantly different analytes in total. Granulocyte colony stimulating factor was the most significantly different analyte (p<0.001). Many of the significant analytes were chemokine ligands found to be linked through an inflammatory pathway promoting T-cell and granulocyte production and activation.

CONCLUSIONS

Our results add further weight to the hypothesis that cancer-related fatigue syndrome is associated with an increased pro-inflammatory immune response. Our findings indicate that these cytokine changes could underpin the subjective symptoms, such as perceived muscle weakness and concentration difficulties, experienced by women who feel fatigued after treatment.

Prognosticating in patients with advanced cancer--observational study comparing the accuracy of clinicians' and patients' estimates of survival

BACKGROUND

Clinicians' prognoses in patients with advanced cancer are imprecise. The aim of this study was to compare doctors', nurses' and patients' survival predictions and to identify factors which influence accuracy.

PATIENTS AND METHODS

Some 1018 patients with advanced cancer were recruited. Survival estimates were obtained from the attending doctor, nurse, multidisciplinary team (MDT) and patient (n = 829, 954, 987 and 290 estimates, respectively) and were compared with actual survival. Clinician and patient characteristics were recorded.

RESULTS

MDTs', doctors' and nurses' predictions were accurate 57.5%, 56.3% and 55.5% of occasions, respectively. Nurses were less accurate than the MDT (P = 0.007) but were no worse than doctors (P = 0.284). Estimates of clinicians and patients were more optimistic (doctors: 31%; nurses: 34%; MDT: 31.1%; patients: 45.1%) than pessimistic (12.7%, 11%, 11.4% and 2.7%). Nurses' accuracy increased if they had reviewed the patient within 24 h. Most patients (61.4%) wanted to know their prognosis. Only 37.1% were willing to offer an estimate regarding their own survival. Patients' prognostic estimates were less accurate than health care professionals' (P < 0.001).

CONCLUSIONS

MDTs were better at predicting survival than doctors' or nurses' alone. Patients were substantially worse. Among nurses, recency of review was related to improved prognostic accuracy.

Psychological Correlates of Mental Stress-induced Ischemia in the Laboratory: The Psychophysiological Investigation of Myocardial Ischemia (PIMI) Study

Participants consisted of 184 patients (160 males, 24 females) with positive angiograms or prior myocardial infarctions who displayed at least 1 mm of ST segment depression on a standardized treadmill test. Mean scores on the Reward Dependence subscale of the Tridimensional Personality Questionnaire were higher in patients displaying ischemia during mental stress. Patients who reported higher levels of irritability/anger in response to the Speech stressor were also more likely to display ischemia. However, this result was primarily a result of the females in the sample whose ratings of interest and irritability were associated with ischemia during the Speech task. Psychometric measures previously found in prospective studies to predict acute cardiac events were unrelated to mental stress-induced ischemia in the laboratory.

Antiphospholipid antibodies prolong the activation of endothelial cells induced by necrotic trophoblastic debris: implications for the pathogenesis of preeclampsia

The symptoms of preeclampsia are preceded by endothelial cell activation/dysfunction which is induced by a placental trigger(s) but maternal risk factor(s) also contribute to the pathogenesis of preeclampsia. In this work we have investigated the interactions of a maternal risk factor, antiphospholipid antibodies, and a placental trigger, necrotic trophoblastic debris, on the activation of endothelial cells. Trophoblastic debris, from placental explants, was induced to become necrotic by freeze-thawing then exposed to endothelial cells for 24 h. After washing away residual trophoblastic debris antiphospholipid antibodies or a control antibody were added to the cultures then replaced with fresh medium in the presence or absence of antibodies. Endothelial cell activation was quantified by examining cell-surface ICAM-1 expression and monocyte adhesion. Endothelial cells exposed to necrotic trophoblastic debris for 24 h became activated but the activation was lost 24 h after removal of the debris. Antiphospholipid antibodies alone did not active untreated endothelial cells, but did prolong the activation of endothelial cells which had been activated by pre-treatment with necrotic trophoblastic debris. When exposed to antiphospholipid antibodies the endothelial cells remained activated despite removal of the trophoblastic debris. In contrast, a control antibody did not prolong endothelial cell activation. Our data suggest that in women with antiphospholipid antibodies, activation of endothelial cells induced by necrotic trophoblastic debris could be maintained even if the endothelial cells were only intermittently exposed to necrotic debris. This might in part explain why antiphospholipid antibodies are such a strong maternal risk factor for preeclampsia.

PP168. The role of calcium supplementation in prevention endothelial cell activation, and possible relevance to preeclampsia

INTRODUCTION

Preeclampsia remains a leading causing of maternal and perinatal mortality and morbidity. Preeclampsia is currently thought to be primarily a disease of endothelial activation and inflammation.

OBJECTIVES

The deportation of trophoblast debris form the placenta was first linked to the pathogenesis of preeclampsia over a hundred years ago and it is hypothesised that deportation of necrotic trophoblast debris may contribute to maternal endothelial cell activation in preeclampsia. We have previously shown that treating placental explants with IL-6 results in shedding of more necrotic trophoblast debris from placental explants and that this debris when phagocytosed by endothelial cells results in activation of the endothelial cells. Although delivery remains the only definitive cure for preeclampsia a number of studies suggest that calcium supplementation may reduce the risk of developing preeclampsia by up to 50% but the protective mechanism of calcium supplementation is unclear. The aim of this work was to determine whether calcium supplementation affects either the production of necrotic trophoblast debris from the placenta or influences endothelial cell activation.

METHODS

First trimester placental explants were cultured with IL-6 in the presence or absence of increasing concentrations of calcium (CaCl2) for 24h. Trophoblastic debris was collected from the explants and then exposed to monolayers of endothelial cell for 24h and endothelial cell activation measured by ICAM-1 ELISA. In other experiments, endothelial cells were treated with IL-6 or necrotic trophoblastic debris in the presence of increasing concentrations of CaCl2, ranging from 230μg/mL to 700μg/mL, for 24h. In some experiments, ebdothelial cells were treated with low concentration of CaCl2, ranging from 0μg/mL to 230μg/mL for 24h. Endothelial cell activation was measured by quantifying cell-surface ICAM-1 levels by ELISA.

RESULTS

CONCLUSION

Our results demonstrate that calcium levels are important to endothelial cell activation and supplemental calcium may reverse the activation of the endothelium induced by proinflammatory mediators while having no effect on the production of trophoblast debris. These results may in part help to explain the benefits of calcium supplementation in the reduction of risk for developing preeclampsia.

Trichosanthin, a Chinese medicine for the medical treatment of ectopic pregnancy with high levels of β-hCG

This was a retrospective study of the effectiveness of trichosanthin (TCS), an active component isolated from the Chinese herb root tuber of Trichosanthes kirilowii on 140 cases of ectopic pregnancy with higher levels of β-human chorionic gonadotropin (β-hCG) managed with a single dose of TCS treatment. Trichosanthin has been used for medical treatment of ectopic pregnancy in China since the 1980s. This study was performed in a major teaching hospitals in China. The mean pretreatment level of β-hCG in the TCS treatment group was 3387.57 IU/L. The success rate of TCS treatment was 85% (119 of 140) which was similar to methotrexate (MTX) treatment. In 86 women with a high level of β-hCG (over 2000 IU/L), the success rate was 80.08% when treated with TCS. Of this group, 26 women who had a high level of β-hCG (over 5000 IU/L) showed a success rate of 73%. The level of β-hCG on days 4, 7, and 10 in TCS group was significantly decreased. This study has shown that TCS may be an option for the medical treatment of unruptured ectopic pregnancy or an option for the treatment of ectopic pregnancy with higher levels of β-hCG than currently recommended for medical management with MTX.

A prevalence study of errors in opioid prescribing in a large teaching hospital

AIM

In 2007, the National Patient Safety Agency performed a study demonstrating that errors in prescribing led to nearly 12,000 adverse clinical incidents a year. The following year, they issued a rapid response report entitled 'Reducing Dosing Errors with Opioid Medicines' designed to be implemented by all NHS trusts. We performed a prevalence study to assess opioid prescribing errors in our large multi-speciality teaching hospital prior to implementation of these recommendations.

METHODOLOGY

We conducted a 1 day snapshot of opioid prescriptions on inpatient drug charts. For every chart, all opioid information was entered into the study proforma. All data were reviewed by consensus group and errors categorised by quality and whether they were potentially lethal, serious, significant or minor.

RESULTS

A total of 330/722 (46%) charts were found to have opioid prescriptions. On the study day, there were 74 charts with errors and on expert review another 16 erroneous charts were found giving a total of 90/330 (27.2%). The largest quality statement error group was 'unclear prescription, missing information'. There were 4 potentially lethal, 26 serious, 38 significant and 22 minor errors.

DISCUSSION

Previous studies have reported opioid prescription error rates of 51.2-70%. Compared with the opioid literature, our trust fares well with an error rate of 27%- four of these errors being potentially lethal. This study has identified where there are weaknesses in our hospital opioid prescribing practice and has aided us in rewriting our acute and chronic pain guidelines with the explicit inclusion of the National Patient Safety Agency recommendations. We have also disseminated the study results at the Trust academic meeting and developed an opioid e-learning package which will be mandatory for all new staff.

Spreading endothelial cell dysfunction in response to necrotic trophoblasts. Soluble factors released from endothelial cells that have phagocytosed necrotic shed trophoblasts reduce the proliferation of additional endothelial cells

The pathogenesis of preeclampsia is not clear but the disease is characterised by systemic endothelial cell dysfunction that is considered to be triggered by a placental factor. Necrotic trophoblastic debris that is deported in the maternal blood is one possible placental trigger for preeclampsia. Syncytial knots were first associated with preeclampsia over 100 years ago. However, syncytial knots are very large and most are trapped in the pulmonary capillaries making it difficult to envisage how they could lead to widespread systemic endothelial cell dysfunction. This study was undertaken to examine whether conditioned medium from endothelial cells that have phagocytosed necrotic trophoblastic debris could adversely affect the proliferation or survival of fresh endothelial cells. Trophoblastic cellular debris, harvested from placental explants was added to endothelial cell monolayers directly or after induction of necrosis by freeze-thawing. Conditioned medium from the endothelial cell cultures was exposed to fresh endothelial cells and their proliferation measured by Alamar Blue, and CyQUANTNF cell proliferation assays. Endothelial cell death was examined by a fluorogenic caspase-3 activity assay and LDH release. Conditioned medium from endothelial cells that had phagocytosed necrotic but not apoptotic trophoblastic debris significantly inhibited the proliferation of fresh endothelial cells but did not induce their death. The conditioned medium also reduced cell-surface endoglin expression by fresh endothelial cells. These results confirm that phagocytosis of necrotic trophoblastic debris by endothelial cells results in the secretion of soluble factors that might explain how necrotic trophoblastic debris trapped in the pulmonary capillaries could induce systemic endothelial cell dysfunction.

Climate response times: dependence on climate sensitivity and ocean mixing

The factors that determine climate response times were investigated with simple models and scaling statements. The response times are particularly sensitive to (i) the amount that the climate response is amplified by feedbacks and (ii) the representation of ocean mixing. If equilibrium climate sensitivity is 3 degrees C or greater for a doubling of the carbon dioxide concentration, then most of the expected warming attributable to trace gases added to the atmosphere by man probably has not yet occurred. This yet to be realized warming calls into question a policy of "wait and see" regarding the issue of how to deal with increasing atmospheric carbon dioxide and other trace gases.

160. THE ROLE OF PHAGOCYTOSIS OF APOPTOTIC SYNCYTIAL KNOTS IN THE PREVENTION OF ENDOTHELIAL CELL ACTIVATION: AN IMPORTANT ADAPTATION FOR NORMAL PREGNANCY

Preeclampsia is characterised by an exaggerated inflammatory response and maternal endothelial cell activation. Syncytial knots, dead multinucleated fetal cells shed from the placenta in large numbers during all pregnancies, may be phagocytosed by maternal endothelial cells. Our previous studies showed that phagocytosis of necrotic but not apoptotic syncytial knots led to endothelial cell activation. It is known that phagocytosis of apoptotic cells leads to active tolerance of immune responses and in this study we questioned whether phagocytosis of apoptotic syncytial knots leads to suppression of the endothelial cells ability to be activated. Syncytial knots were harvested from 1st trimester placental explants. Monolayers of endothelial cells were pre-treated with apoptotic syncytial knots for 24 h. After washing, the endothelial cells were treated with the endothelial cell activators LPS, PMA, IL-6, or necrotic syncytial knots for 24 h. In some experiments the inhibitor of phagocytosis, cytochalasin D, was added into the cultures along with apoptotic syncytial knots. Endothelial cell-surface ICAM-1 was measured using cell based ELISAs. Expression of ICAM-1 by endothelial cells that had phagocytosed apoptotic syncytial knots prior to treatment with LPS, PMA, IL-6, or necrotic syncytial knots was significantly (P =/<0.003) reduced, compared to control endothelial cells that had not phagocytosed apoptotic syncytial knots. Inhibiting phagocytosis of apoptotic syncytial knots with cytochalasin D abolished this protective effect. Our data suggest phagocytosis of apoptotic syncytial knots results in the suppression of the ability of endothelial cells to be activated by a number of potent chemical activators, as well as by the physiologically relevant activator, necrotic syncytial knots. This work suggests that the release of apoptotic syncytial knots from the placenta during normal pregnancy may be a mechanism by which the fetus attempts to protect the maternal vasculature against activation.

Anti-phospholipid antibodies increase non-apoptotic trophoblast shedding: a contribution to the pathogenesis of pre-eclampsia in affected women?

Pre-eclampsia is associated with trophoblast shedding-deportation and endothelial cell dysfunction. Anti-phospholipid autoantibodies increase a women's risk factor of developing pre-eclampsia. In this study we examined the hypothesis that anti-phospholipid antibodies alter the number and nature of trophoblasts shed from the placenta, and that phagocytosis of these altered trophoblasts results in endothelial cell activation. To investigate this we used a placental explant model in which explants were treated with anti-phospholipid antibodies. This treatment resulted in a doubling of the amount of trophoblast shed from the explants. Furthermore, the trophoblasts shed from anti-phospholipid antibody-treated explants were more readily phagocytosed by endothelial cells and subsequently caused the activation of the endothelial cells, as indicated by increased expression of endothelial cell surface ICAM-1 determined by cell-based ELISA, and monocyte adhesion as determined by flow cytometry. Confocal microscopy analysis of trophoblasts shed from anti-phospholipid antibody-treated or control explants demonstrated that anti-phospholipid antibodies, but not control antibodies, were internalised within trophoblasts shed from the explants, and this was accompanied by a reduction in the activity of caspases 3 and 7 in the shed trophoblasts as indicated by FLICA. These results suggest that anti-phospholipid antibodies are selectively transported into trophoblasts where they affect the regulation of the cell cycle leading to excess and aberrant death (necrotic or aponecrotic) and shedding of trophoblasts. If reflected in vivo this might explain, at least in part, how anti-phospholipid antibodies contribute to the pathogenesis of pre-eclampsia.

Circadian heart rate response to chronotherapy versus conventional therapy in patients with hypertension and myocardial ischemia

BACKGROUND

Changes in heart rate (HR) may contribute to the higher incidence of cardiovascular events in the morning.

HYPOTHESIS

The objectives of this analysis were to assess HR patterns in two populations (patients with chronic stable angina or stage I to III hypertension) and to compare the effects of various antianginal and antihypertensive treatments on HR.

METHODS

This was a retrospective analysis of HR data from two clinical trials evaluating the efficacy of controlled-onset, extended-release (COER)-verapamil. The effects of COER-verapamil were compared with placebo, nifedipine gastrointestinal therapeutic system (GITS), amlodipine, and the combination of amlodipine and atenolol.

RESULTS

In patients with angina (n = 498), the change from baseline in HR following 4 weeks of treatment was -6.7 +/- 10.5 beats/min in the COER-verapamil group, -10.8 +/- 10.8 beats/min in the amlodipine/atenolol group, + 2.5 +/- 9.1 beats/ min in the amlodipine monotherapy group, and -1.3 +/- 10.5 beats/min in the placebo group (p<0.001). Data were stratified based on whether patients experienced asymptomatic ischemia during baseline ambulatory electrocardiographic monitoring. The circadian HR pattern was morphologically similar in all groups; however, differences in the magnitude of HR response were evident. In the subset of patients with asymptomatic ischemia (n = 101), treatment with amlodipine monotherapy increased HR compared with placebo. In this same subset of patients, HR reductions were achieved with COER-verapamil and amlodipine/atenolol. In patients with hypertension (n = 557), the change in HR following 10 weeks of treatment was -3.3 beats/min for patients treated with COER-verapamil compared with + 2.0 beats/min for patients treated with nifedipine GITS (p < 0.0001, between-group differences).

CONCLUSION

This analysis demonstrates that morphologically similar circadian patterns of HR occur in both hypertensive patients and those with angina. In addition, significant variation exists among antianginal and antihypertensive agents regarding HR effects.

528. THE INTERNALIZATION OF ANTIPHOSPHOLIPID ANTIBODIES INTO TROPHOBLASTS CORRELATES WITH THE EXPRESSION OF MEGALIN

Antiphospholipid antibodies (aPL) are autoantibodies that increase the risk of preeclampsia nine fold. We have recently shown aPL increase in the number of syncytial knots shed from placental explants and also change the trophoblast death process towards necrosis. Shedding of necrotic syncytial knots is thought to contribute to the pathogenesis of preeclampsia. Antiphospholipid antibodies but not control antibodies, are internalised into the syncytiotrophoblast suggesting a specific mechanism for internalisation of the aPL. Megalin is known to be an endocytic receptor for the antigen of aPL. We believe that the internalisation of aPL into the syncytiotrophoblast is required to for aPL to affect trophoblast shedding and in this study began to investigate the hypothesis that megalin mediates aPL-internalisation. Monoclonal aPL, IIC5 or ID2, were incubated with monolayers of the trophoblast cell lines, Jar, Jeg 3 or BeWo, or first trimester placental explants for 24 hours. Internalisation of aPL into trophoblasts was determined by fluorescent immuno-staining as was the expression of megalin using an antimegalin antibody (Sigma). Experiments were repeated at least three times. Confocal microscopy demonstrated that the syncytiotrophoblast of explants and BeWo cells, but not Jar or Jeg3 cells, internalised the aPL. Despite treating explants and BeWos with the same amount of aPL the level of aPL internalised by the syncytiotrophoblast of explants was greater than the level internalised by BeWos. Megalin was expressed strongly by the syncytiotrophoblast and weakly by BeWos but was not expressed by Jars or Jeg3 cells. The internalization of aPL into syncytiotrophoblasts may play an important role in regulating trophoblast death leading to aberrant shedding of syncytial knots. This study provides preliminary evidence that megalin expression correlates with the ability of trophoblasts to internalize aPL suggesting it may be the receptor that mediates aPL internalization into trophoblasts making this pathway a potential therapeutic target.

Development and validation of a prognostic scale for use in patients with advanced cancer

The aim of this study was to develop a new prognostic indicator to help predict survival in advanced cancer patients more accurately. Data on 329 patients obtained from a multi-centre study in London were analysed. A multifactorial Cox regression model was applied and validated using bootstrapping techniques. Predictive scores were calculated and used to produce a new prognostic index. The value of the index in predicting 14-day survival was then assessed. Four variables were found to be associated with worse survival: primary lung cancer, secondary liver cancer, raised C-Reactive protein and poor performance status (ECOG 4). Survival curves showed that patients designated as 'high' risk by the resulting index had significantly shorter survival than those designated as 'low' risk. A high score on the newly derived prognostic index is associated with poorer survival, but its clinical utility is limited by the relatively low predictive probability of the score.

A systematic review of the scales used for the measurement of cancer-related fatigue (CRF)

BACKGROUND

Fatigue in cancer is very common and can be experienced at all stages of disease and in survivors. There is no accepted definition of cancer-related fatigue (CRF) and no agreement on how it should be measured. A number of scales have been developed to quantify the phenomenon of CRF. These vary in the quality of psychometric properties, ease of administration, dimensions of CRF covered and extent of use in studies of cancer patients. This review seeks to identify the available tools for measuring CRF and to make recommendations for ongoing research into CRF.

METHODS

A systematic review methodology was used to identify scales that have been validated to measure CRF. The inclusion criteria required the scale to have been validated for use in cancer patients and/or widely used in this population. Scales also had to meet a minimum quality score for inclusion.

RESULTS

The reviewers identified 14 scales that met the inclusion criteria. The most commonly used scales and best validated were the Functional Assessment of Cancer Therapy Fatigue (FACT F), the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C30) (fatigue subscale) and the Fatigue Questionnaire (FQ).

CONCLUSIONS

Unidimensional scales are the easiest to administer and have been most widely used. The authors recommend the use of the EORTC QLQ C30 fatigue subscale or the FACT F. The FQ gives a multidimensional assessment and has also been widely used. A substantial minority of the scales identified have not been used extensively or sufficiently validated in cancer patients and cannot be recommended for routine use without further validation.

A Multiagent Approach to Autonomous Intersection Management

Artificial intelligence research is ushering in a new era of sophisticated, mass-market transportation technology. While computers can already fly a passenger jet better than a trained human pilot, people are still faced with the dangerous yet tedious task of driving automobiles. Intelligent Transportation Systems (ITS) is the field that focuses on integrating information technology with vehicles and transportation infrastructure to make transportation safer, cheaper, and more efficient. Recent advances in ITS point to a future in which vehicles themselves handle the vast majority of the driving task. Once autonomous vehicles become popular, autonomous interactions amongst multiple vehicles will be possible. Current methods of vehicle coordination, which are all designed to work with human drivers, will be outdated. The bottleneck for roadway efficiency will no longer be the drivers, but rather the mechanism by which those drivers' actions are coordinated. While open-road driving is a well-studied and more-or-less-solved problem, urban traffic scenarios, especially intersections, are much more challenging. We believe current methods for controlling traffic, specifically at intersections, will not be able to take advantage of the increased sensitivity and precision of autonomous vehicles as compared to human drivers. In this article, we suggest an alternative mechanism for coordinating the movement of autonomous vehicles through intersections. Drivers and intersections in this mechanism are treated as autonomous agents in a multiagent system. In this multiagent system, intersections use a new reservation-based approach built around a detailed communication protocol, which we also present. We demonstrate in simulation that our new mechanism has the potential to significantly outperform current intersection control technology -- traffic lights and stop signs. Because our mechanism can emulate a traffic light or stop sign, it subsumes the most popular current methods of intersection control. This article also presents two extensions to the mechanism. The first extension allows the system to control human-driven vehicles in addition to autonomous vehicles. The second gives priority to emergency vehicles without significant cost to civilian vehicles. The mechanism, including both extensions, is implemented and tested in simulation, and we present experimental results that strongly attest to the efficacy of this approach.

Drug therapy for the management of cancer related fatigue

BACKGROUND

Cancer related fatigue (CRF) is common, under-recognised and difficult to treat. There have been trials looking at drug interventions to improve CRF but results have been conflicting depending on the population studied and outcome measures used. No previous reviews of this topic have been exhaustive or have synthesised all available data.

OBJECTIVES

To assess the efficacy of drugs for the management of CRF.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (1st Quarter 2007), MEDLINE (1966 to March 2007) and a selection of cancer journals. We searched references of identified articles and contacted authors to obtain unreported data.

SELECTION CRITERIA

Trials were included in the review if they 1) assessed drug therapy for the management of CRF compared to placebo, usual care or a non-pharmacological intervention in 2) randomised controlled trials (RCT) of 3) adult patients with a clinical diagnosis of cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Meta-analyses were performed on different drug classes using continuous variable data.

MAIN RESULTS

Forty-five trials met the inclusion criteria. Only 27 of these trials involving 6746 participants were judged to have used a sufficiently robust measure of fatigue and thus were deemed suitable for detailed analysis. The drugs were analysed by class (psychostimulants; haemopoetic growth factors; antidepressants and progestational steroids). Methylphenidate showed a small but significant improvement in fatigue over placebo (Z = 2.40; P = 0.02). Erythropoietin showed a small but significant improvement in fatigue (for anaemic patients receiving chemotherapy) compared to placebo (Z = 2.67; P = 0.008). Darbopoietin also demonstrated a smaller but significant improvement in fatigue over placebo (Z = 1.96; P = 0.05). Paroxetine and progestational steroids demonstrated no superiority over placebo in treating CRF. There was a very high degree of statistical and clinical heterogeneity in the trials and the reasons for this are discussed. It was not possible to determine optimum doses as a result of this review.

AUTHORS' CONCLUSIONS

Erythropoietin and darbopoetin (for anaemic patients on chemotherapy) and psychostimulant trials provide evidence for improvement in CRF at a clinically meaningful level. There are no data to support the use of paroxetine or progestational steroids for the treatment of CRF. The obvious candidate drug for use in a large scale RCT is methylphenidate to confirm the preliminary results from this review.