***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: PURPOSE The chronic fatigue syndrome ( CFS ) is characterized by profound fatigue , neuropsychiatric dysfunction , and frequent abnormalities in cell-mediated immunity . No effective therapy is known . PATIENTS AND METHODS Forty-nine patients ( 40 with abnormal cell-mediated immunity ) participated in a r and omized , double-blind , placebo-controlled trial to determine the effectiveness of high-dose intravenously administered immunoglobulin G. The patients received three intravenous infusions of a placebo solution or immunoglobulin at a dose of 2 g/kg/month . Assessment of the severity of symptoms and associated disability , both before and after treatment , was completed at detailed interviews by a physician and psychiatrist , who were unaware of the treatment status . In addition , any change in physical symptoms and functional capacity was recorded using visual analogue scales , while changes in psychologic morbidity were assessed using patient-rated indices of depression . Cell-mediated immunity was evaluated by T-cell subset analysis , delayed-type hypersensitivity skin testing , and lymphocyte transformation with phytohemagglutinin . RESULTS At the interview conducted by the physician 3 months after the final infusion , 10 of 23 ( 43 % ) immunoglobulin recipients and three of the 26 ( 12 % ) placebo recipients were assessed as having responded with a substantial reduction in their symptoms and recommencement of work , leisure , and social activities . The patients design ated as having responded had improvement in physical , psychologic , and immunologic measures ( p less than 0.01 for each ) . CONCLUSION Immunomodulatory treatment with immunoglobulin is effective in a significant number of patients with CFS , a finding that supports the concept that an immunologic disturbance may be important in the pathogenesis of this disorder Abstract Objective : To assess the efficacy of an educational intervention explaining symptoms to encourage grade d exercise in patients with chronic fatigue syndrome . Design : R and omised controlled trial . Setting : Chronic fatigue clinic and infectious diseases outpatient clinic . Subjects : 148 consecutively referred patients fulfilling Oxford criteria for chronic fatigue syndrome . Interventions : Patients r and omised to the control group received st and ardised medical care .  Patients r and omised to intervention received two individual treatment sessions and two telephone follow up calls , supported by a comprehensive educational pack , describing the role of disrupted physiological regulation in fatigue symptoms and encouraging home based grade d exercise . The minimum intervention group had no further treatment , but the telephone intervention group received an additional seven follow up calls and the maximum intervention group an additional seven face to face sessions over four months . Main outcome measure : A score of 25 or an increase of 10 on the SF-36 physical functioning subscale ( range 10 to 30 ) 12 months after r and omisation . Results : 21 patients dropped out , mainly from the intervention groups . Intention to treat analysis showed 79 ( 69 % ) of patients in the intervention groups achieved a satisfactory outcome in physical functioning compared with two ( 6 % ) of controls , who received st and ardised medical care ( P<0.0001 ) . Similar improvements were observed in fatigue , sleep , disability , and mood . No significant differences were found between the three intervention groups . Conclusions : Treatment incorporating evidence based physiological explanations for symptoms  was effective in encouraging self managed grade d exercise . This result ed in substantial improvement compared with st and ardised medical care BACKGROUND Fatigue is a common symptom for which patients consult their doctors in primary care . With usual medical management the majority of patients report that their symptoms persist and become chronic . There is little evidence for the effectiveness of any fatigue management in primary care . AIM To compare the effectiveness of cognitive behaviour therapy ( CBT ) with counselling for patients with chronic fatigue and to describe satisfaction with care . DESIGN OF STUDY R and omised trial with parallel group design . SETTING Ten general practice s located in London and the South Thames region of the United Kingdom recruited patients to the trial between 1996 and 1998 . Patients came from a wide range of socioeconomic background s and lived in urban , suburban , and rural areas . METHOD Data were collected before r and omisation , after treatment , and six months later . Patients were offered six sessions of up to one hour each of either CBT or counselling . Outcomes include : self-report of fatigue symptoms six months later , anxiety and depression , symptom attributions , social adjustment and patients ' satisfaction with care . RESULTS One hundred and sixty patients with chronic fatigue entered the trial , 45 ( 28 % ) met research criteria for chronic fatigue syndrome ; 129 completed follow-up . All patients met Chalder et al 's st and ard criteria for fatigue . Mean fatigue scores were 23 on entry ( at baseline ) and 15 at six months ' follow-up . Sixty-one ( 47 % ) patients no longer met st and ard criteria for fatigue after six months . There was no significant difference in effect between the two therapies on fatigue ( 1.04 [ 95 % CI = -1.7 to 3.7 ] ) , anxiety and depression or social adjustment outcomes for all patients and for the subgroup with chronic fatigue syndrome . Use of antidepressants and consultations with the doctor decreased after therapy but there were no differences between groups . CONCLUSION Counselling and CBT were equivalent in effect for patients with chronic fatigue in primary care . The choice between therapies can therefore depend on other considerations , such as cost and accessibility OBJECTIVE Cognitive behavior therapy for chronic fatigue syndrome was compared with relaxation in a r and omized controlled trial . METHODS Sixty patients with chronic fatigue syndrome were r and omly assigned to 13 sessions of either cognitive behavior therapy ( grade d activity and cognitive restructuring ) or relaxation . Outcome was evaluated by using measures of functional impairment , fatigue , mood , and global improvement . RESULTS Treatment was completed by 53 patients .  Functional impairment and fatigue improved more in the group that received cognitive behavior therapy . At final follow-up , 70 % of the completers in the cognitive behavior therapy group achieved good outcomes ( substantial improvement in physical functioning ) compared with 19 % of those in the relaxation group who completed treatment . CONCLUSIONS Cognitive behavior therapy was more effective than a relaxation control in the management of patients with chronic fatigue syndrome . Improvements were sustained over 6 months of follow-up CONTEXT Chronic fatigue syndrome ( CFS ) is associated with a dysregulated hypothalamic-pituitary adrenal axis and hypocortisolemia . OBJECTIVE To evaluate the efficacy and safety of low-dose oral hydrocortisone as a treatment for CFS . DESIGN A r and omized , placebo-controlled , double-blind therapeutic trial , conducted between 1992 and 1996 . SETTING A single-center study in a tertiary care research institution . PATIENTS A total of 56 women and 14 men aged 18 to 55 years who met the 1988 Centers for Disease Control and Prevention case criteria for CFS and who withheld concomitant treatment with other medications . INTERVENTION Oral hydrocortisone , 13 mg/m2 of body surface area every morning and 3 mg/m2 every afternoon , or placebo , for approximately 12 weeks . MAIN OUTCOME MEASURES A global Wellness scale and other self-rating instruments were completed repeatedly before and during treatment . Resting and cosyntropin-stimulated cortisol levels were obtained before and at the end of treatment . Patients recorded adverse effects on a checklist . RESULTS The number of patients showing improvement on the Wellness scale was 19 ( 54.3 % ) of 35 placebo recipients vs 20 ( 66.7 % ) of 30 hydrocortisone recipients ( P = .31 ) . Hydrocortisone recipients had a greater improvement in mean Wellness score ( 6.3 vs 1.7 points ; P=.06 ) , a greater percentage ( 53 % vs 29 % ; P=.04 ) recording an improvement of 5 or more points in Wellness score , and a higher average improvement in Wellness score on more days than did placebo recipients ( P<.001 ) . Statistical evidence of improvement was not seen with other self-rating scales . Although adverse symptoms reported by patients taking hydrocortisone were mild , suppression of adrenal glucocorticoid responsiveness was documented in 12 patients who received it vs none in the placebo group ( P<.001 ) . CONCLUSIONS Although hydrocortisone treatment was associated with some improvement in symptoms of CFS , the degree of adrenal suppression precludes its practical use for CFS PURPOSE To evaluate the potential benefit of immunologic therapy with dialyzable leukocyte extract and psychologic treatment in the form of cognitive-behavioral therapy ( CBT ) in patients with chronic fatigue syndrome ( CFS ) . PATIENTS AND METHODS Immunologic and psychologic treatments were administered to 90 adult patients who fulfilled diagnostic criteria for CFS in a double-blind , r and omized , and placebo-controlled study . A four-cell trial design allowed the assessment of benefit from immunologic and psychologic treatment individually or in combination . Outcome was evaluated by measurement of global well-being ( visual analogue scales ) , physical capacity ( st and ardized diaries of daily activities ) , functional status ( Karnofsky performance scale ) , and psychologic morbidity ( Profile of Mood States question naire ) , and cell-mediated immunity was evaluated by peripheral blood T-cell subset analysis and delayed-type hypersensitivity skin testing . RESULTS Neither dialyzable leukocyte extract nor CBT ( alone or in combination ) provided greater benefit than the nonspecific treatment regimens . CONCLUSIONS In this study , patients with CFS did not demonstrate a specific response to immunologic and /or psychologic therapy . The improvement recorded in the group as a whole may reflect both nonspecific treatment effects and a propensity to remission in the natural history of this disorder BACKGROUND Chronic fatigue syndrome ( CFS ) is a disorder of unknown etiology , consisting of prolonged , debilitating fatigue , and a multitude of symptoms including neurocognitive dysfunction , flu-like symptoms , myalgia , weakness , arthralgia , low- grade fever , sore throat , headache , sleep disturbances , and swelling and tenderness of lymph nodes . No effective treatment for CFS is known . OBJECTIVE The purpose of the study was to evaluate the efficacy of the reduced form of nicotinamide adenine dinucleotide ( NADH ) i.e. , ENADA the stabilized oral absorbable form , in a r and omized , double-blind , placebo-controlled crossover study in patients with CFS . Nicotinamide adenine dinucleotide is known to trigger energy production through ATP generation which may form the basis of its potential effects . METHODS Twenty-six eligible patients who fulfilled the Center for Disease Control and Prevention criteria for CFS completed the study . Medical history , physical examination , laboratory studies , and question naire were obtained at baseline , 4 , 8 , and 12 weeks . Subjects were r and omly assigned to receive either 10 mg of NADH or placebo for a 4-week period . Following a 4-week washout period , subjects were crossed to the alternate regimen for a final 4-week period . RESULTS No severe adverse effects were observed related to the study drug . Within this cohort of 26 patients , 8 of 26 ( 31 % ) responded favorably to NADH in contrast to 2 of 26 ( 8 % ) to placebo . Based upon these encouraging results we have decided to conduct an open-label study in a larger cohort of patients . CONCLUSION Collectively , the results of this pilot study indicate that NADH may be a valuable adjunctive therapy in the management of the chronic fatigue syndrome and suggest that further clinical trials be performed to establish its efficacy in this clinical ly perplexing disorder Caffeine consumption , a ubiquitous cultural phenomenon with significant health implication s may be governed by some of the same principles which affect other drug use [ 1 ] . We hypothesized that pharmacological and expectancy effects may be two of those principles . A balanced placebo design was used with 100 male undergraduates to separate caffeine 's active drug effects from the expectancy of having consumed caffeine on mood , performance , and physiological measures . The manipulation of expectancies was highly effective on subjects ' judgments of caffeine dosage , regardless of actual caffeine content . As predicted , expectancy set and caffeine content appeared equally powerful , and worked additively , to affect subjects ' ratings of how much the coffee influenced their mood and performance . Main effects on systolic and diastolic blood pressure , pulse rate , and a fatigue measure were found for caffeine vs. no caffeine groups only . Additional increases in diastolic blood pressure for smokers were noted within the caffeine-receiving conditions . Results are discussed with heuristic and health implication Abstract Objective : To evaluate the acceptability and efficacy of adding cognitive behaviour therapy to the medical care of patients presenting with the chronic fatigue syndrome . Design : R and omised controlled trial with final assessment at 12 months . Setting : An infectious diseases outpatient clinic . Subjects : 60 consecutively referred patients meeting consensus criteria for the chronic fatigue syndrome . Interventions : Medical care comprised assessment , advice , and follow up in general practice . Patients who received cognitive behaviour therapy were offered 16 individual weekly sessions in addition to their medical care . Main outcome measures : The proportions of patients ( a ) who achieved normal daily functioning ( Karnofsky score 
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In contrast with the conventional wisdom , the placebo response in CFS is low .
Psychological-psychiatric interventions were shown to have a lower placebo response , perhaps linked to patient expectations