Article

Evaluation of the Reliability and Validity of the Persian Version of the Fatigue Assessment Scale in Iranian Sarcoidosis Patients

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INTRODUCTION: Fatigue is one of the common symptoms of sarcoidosis, which occurs in about 50-70% of patients. AIM: Considering that there are no valid Iranian questionnaires for evaluating fatigue in sarcoidosis, in the present study, for the first time, we translated Fatigue Questionnaire into Persean and evaluated its validity and reliability among Iranian patients with sarcoidosis. MATERIAL AND METHODS: In methodological research, English version of Fatigue assessment scale (FAS) 10 items questionnaire which is designed to assess physical or mental fatigue in chronic disease patients, was translated into Persian and back-translated into English. Its validity and reliability were studied on the one hundred and thirteen confirmed sarcoidosis patients are referring to respiratory referral hospital of Iran. Reliability analysis was performed by estimation of Cronbach`s alpha test. RESULTS: According to the cut-off point of 22.84 (74%) of the studied patients were suffering from fatigue. The internal consistency calculation revealed that the alpha value of the physical fatigue and mental fatigue was 0.945 and 0.896, respectively. CONCLUSION: We concluded that the existence of questions number 4 and 10 in the questionnaire reduces the continuity of the questions, and therefore we suggest applying the FAS questionnaire without the two questions 4 and 10. This study showed that FAS questionnaire was very practical and can routinely be applied to assess the fatigue scale in sarcoidosis patients.
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ID Design Press, Skopje, Republic of Macedonia
Open Access Macedonian Journal of Medical Sciences. 2018 Jul 20; 6(7):1310-1314.
https://doi.org/10.3889/oamjms.2018.242
eISSN: 1857-9655
Public Health
Evaluation of the Reliability and Validity of the Persian Version of
the Fatigue Assessment Scale in Iranian Sarcoidosis Patients
Somayeh Lookzadeh1, Arda Kiani2, Kimia Taghavi1, Shirin Kianersi1, Habib Emami3, Maryam Mirenayat1, Atefeh Abedini1*
1Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD),
Shahid Beheshti University of Medical Sciences, Tehran, Iran; 2Tracheal Diseases Research Center, National Research
Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran;
3Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Disease
(NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
Citation: Lookzadeh S, Kiani A, Taghavi K, Kianersi S,
Emami H, Mirenayat M, Abedini A. Evaluation of the
Reliability and Vali dity of the Persian Version of the
Fatigue Assessment Scale i n Iranian Sarcoidosis
Patients. Open Access Maced J Med Sci. 2018 Jul 20;
6(7):1310-1314. https://doi.org/10.3889/oamjms.2018.242
Keywords: Granuloma; Sarcoidosis; Reliability; Validity;
Fatigue Assessment Scale
*Correspondence: Atefeh Abedini. Chronic Respiratory
Diseases Research Center, National Research Institute of
Tuberculosis and Lung Diseases (NRITLD), Shahid
Beheshti University of Medical Sciences, Tehran, Iran. E-
mail: dr.abedini110@sbmu.ac.ir
Received: 22-Mar-2018; Revised: 13-Jun-2018;
Accepted: 14-Jun-2018; Online first: 14-Jul-2018
Copyright: © 2018 Somayeh Lookzadeh, Arda Kiani,
Kimia Taghavi, Shirin Kianersi, Habib Emami, Maryam
Mirenayat, Atefeh Abedini. This is an open-access article
distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 International Li cense (CC
BY-NC 4.0)
Funding: This research did not receive any financial
support
Competing Interests: The authors have declared that no
competing interests exist
Abstract
INTRODUCTION: Fatigue is one of the common symptoms of sarcoidosis, which occurs in about 50-70% of
patients.
AIM: Considering that there are no valid Iranian questionnaires for evaluating fatigue in sarcoidosis, in the present
study, for the first time, we translated Fatigue Questionnaire into Persean and evaluated its validity and reliability
among Iranian patients with sarcoidosis.
MATERIAL AND METHODS: In methodological research, English version of Fatigue assessment scale (FAS) 10
items questionnaire which is designed to assess physical or mental fatigue in chronic disease patients, was
translated into Persian and back-translated into English. Its validity and reliability were studied on the one hundred
and thirteen confirmed sarcoidosis patients are referring to respiratory referral hospital of Iran. Reliability analysis
was performed by estimation of Cronbach`s alpha test.
RESULTS: According to the cut-off point of 22.84 (74%) of the studied patients were suffering from fatigue. The
internal consistency calculation revealed that the alpha value of the physical fatigue and mental fatigue was 0.945
and 0.896, respectively.
CONCLUSION: We concluded that the existence of questions number 4 and 10 in the questionnaire reduces the
continuity of the questions, and therefore we suggest applying the FAS questionnaire without the two questions 4
and 10. This study showed that FAS questionnaire was very practical and can routinely be applied to assess the
fatigue scale in sarcoidosis patients.
Introduction
Sarcoidosis is a chronic inflammatory disease
with an unknown cause with non-caseating
granulomas manifestations in different organs [1] [2].
The outbreak varies from one region to another, and
the general prevalence is about 5-40 cases per
100,000 [3]. Sarcoidosis occurs at all ages, but the
highest incidence in patients has been observed in the
second and sixth decades of their life [4]. Clinical
manifestations include systemic and general signs of
fatigue, weight loss, fever, discomfort, and the
involvement of specific organs such as the lungs, skin,
eyes, heart, liver, joints and the nervous system [1].
The commonly involved organ is a lung.
Furthermore, additional pulmonary
involvements occur in 25-30% of patients [2] [3].
Fatigue is one of the common symptoms of
sarcoidosis, which occurs in about 50-70% of patients.
The definitive cause of fatigue is unknown and is
influenced by numerous factors [3] [5]. This symptom
is associated with many chronic physical illnesses,
such as multiple sclerosis, Parkinson's disease,
rheumatoid arthritis, and psychiatric disorders such as
depression [6]. The formation of granuloma and the
release of cytokines may be factors of the beginning
of fatigue in sarcoidosis [7]. Fatigue is more common
Lookzadeh et al. Evaluation of the Reliability and Validity of the Persian Version of the Fatigue Assessment Scale
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during the active period of the disease, as well as
depression, cognitive impairment, exercise
intolerance, and stress associated with sarcoidosis [8]
[9]. In addition to the mentioned factors, it seems that
changing the quality of life and the impact on
occupational and social activities resulting from
sarcoidosis are effective in fatigue. There is no
agreement on the physical and mental contrast.
Fatigue is seen as a bilateral contrast [10], but many
authors still consider it a multi-dimensional structure
[11]. Different dimensions of fatigue and general
dissonance for fatigue definition are used to evaluate
fatigue in different questionnaires. Fatigue associated
scale (FAS) is the most reliable questionnaire in the
study of fatigue in chronic disease patients. Fatigue
assessment Scale is a selfreporting questionnaire.
FAS questionnaire is a one-dimensional scale for
fatigue testing and consists of 10 questions that
examine five physical fatigue and five mental health
issues. The whole amount of fatigue and its severity is
presented by a total score is between 10 and 50 [3]
[12]. This study aimed to assess the fatigue
manifestations in Iranian sarcoidosis patients.
Considering that there are no valid Iranian
questionnaires for the evaluation of fatigue in
sarcoidosis, we evaluated the reliability and validity of
the first Persian translation of fatigue associated
scale, which was accomplished by the same research
group.
Material and Methods
In methodological research, English version of
the Fatigue assessment scale (FAS) was translated
into Persian and back-translated into English. Its
validity and reliability were studied.
One hundred and thirteen confirmed
sarcoidosis patients are referring to respiratory referral
hospital in Iran, who were over 18 years old, were
included in the present study. Written consent was
obtained from patients for participation in the study.
The entry clause in this study was the person's ability
to complete the questionnaire without the help of
others. The study was approved by the University
Ethics Committee.
The FAS included 10 questions with a five-
point response "1 = never" to "5-always". Items were
divided into two parts of physical and mental fatigue,
and each section contained five questions. Therefore,
the total number was between 10 and 50. Except for
questions number 4 (I have enough energy for
everyday life) and 10 (I can focus very well when I'm
busy doing), which represent positive issues, the
remaining eight questions out of 10, were negatively
related issues. Thus, before the analysis of the data,
the answers to items 4 and10 were reversed.
Translation and back translation was
conducted based on convenient guidelines [15] [16].
Steps of the process of translating and validating the
questionnaire were as followed.
Step 1: Inviting an expert committee involving
two nurses, one epidemiologist and one
pulmonologist. All steps of translation/back translation
and validity performance of the questionnaire were
supervised by this committee.
Step 2: English version of the questionnaire
was simultaneously translated into Persian, by two
independent native interpreters. The two versions
were compared, and the translators were asked to
mention the applied changes to the items during
translation. The two copies were compared by the
expert committee to reach agreement about the final
version.
Step 3: The final Persian translation was
back-translated into English, by an English-speaking
expert in the United States. The expert committee
confirmed the final Persian version and inserted it in
the validity and reliability step.
Step 4: Face to face Content reliability
For the face to face reality of the
questionnaire, a copy of the final Persian translation of
it was given to 15 patients. They were asked to give
their opinion on each item and to note the meaning of
each question. They were also asked to declare
whether they understood the concept of the questions.
Finally, their opinion was evaluated to approve the
principle of the questionnaire.
Reliability analysis was performed by
estimation of Cronbach`s alpha. The internal
consistency of the questionnaire was assessed by
Cronbach`s alpha coefficient, and alpha of equal or
greater than 0.70 was considered as satisfactory [17].
For the repeatability, the test was performed again,
and the analysis was retested.
In qualitative reliability, the 15 patients were
asked to comment on each item's grammar, the use of
proper words, dictionaries, the clarity of the concept of
the words and the simplicity of completing the
questionnaire. Subsequently, according to their views,
the phrases were reviewed and modified.
Step 5 construct validity: To determine the
reliability, we distributed two copies of the
questionnaire among 15 patients in two weeks
interval. We determined the reliability of the
questionnaire by calculating the correlation between
the first and second answers. For estimating the
reliability, the internal correlation of the Cronbach's
alpha index was calculated. Items with results above
70% were kept in the questionnaire. The analysis of
the parameters was done using the varimax rotation
program.
Finally, 113 sarcoidosis patients have entered
the study after signing the informed consent.
Public Health
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Results
One hundred and thirteen confirmed cases of
sarcoidosis were admitted in the study. Of these, 70
(61%) were male, and 45 (39%) were female. Mean
age of the patients was 38.77 ± 9.65. Males and
females were 38.06 ± 8.95 and 39.9 ± 10.66 years old
respectively. There was no ceiling or floor factor
effect. Three patients (2.7%) had the lowest possible
FAS score with the point of 10, and none of the
patients could catch the maximum score of 50. Mean
FAS score was not different in males (27.8 ± 9.57)
comparing to females (27.06 ± 9.59) (t = 0.424, df =
111, P = 0.672).
None of the translators suggested any
changes to the final Farsi version. Cronbach’s alpha
after reversing items 4 and 10 was 0.76 which is
acceptable [18]. Table 1 represents item reliability
results, means and standard deviation, Item-total
correlation, ceiling and floor effects. Total Cronbach`s
alpha was not increased by eliminating none of the
items. The total correlations for the total items were
positive (u > 50) and ranged from 0.52 to 0.82. We
also evaluated internal consistency using Cronbach`s
alpha once without reversing item four and item 10
and after eliminating these two items and the results
were 0.93 and 0.927 respectively.
Table 1: Item reliability results, means and standard deviation,
Item-total correlation, ceiling and floor effects
Items
N
Mean
SD
Correct
item-total
correlation
Alpha
Ceiling
effect
I am bothered by fatigue
113
2.7
1.35
0.79
0.68
11.3
I get tired very quickly
113
3.06
1.4
0.82
0.67
19.1
I don’t do much during the
day
113
2.81
1.20
0.83
0.68
9.6
I have enough energy for
everyday life
113
2.85
1.20
0.62
0.86
9.6
Physically, I feel
exhausted
113
3.24
1.33
0.80
0.68
24.3
I have problems to start
things
113
2.59
1.30
0.70
0.70
9.6
I have problems to think
clearly
113
2.29
1.20
0.61
0.71
5.2
I feel no desire to do
anything
113
2.38
1.07
0.70
0.70
3.5
Mentally, I feel exhausted
113
2.53
1.06
0.52
0.73
7.0
When I am doing
something, I can
concentrate quite well
113
3.20
1.03
0.55
0.84
3.5
Total scone
113
27.56
9.54
The overall KMO for the set of the items
included in the analysis was 0.80 which was above
the 50% of the minimum requirement for the
coefficient KMO (Table 2).
Table 2: KMO and Bartlett’s Test
Kaiser-Mayer-Olkin Measures of Sampling
Accuracy
0.898
Bartlett´s Test of Approx.Chi-Square
Sphericity
960.746
df
45
Sig
< 0.0001
The test was correlated with the Bartlett test
(0.00) and was appropriate for factor analysis. Based
on the variance factor of more than one (Eigenvalue >
1), two factors were extracted which were 76.544% of
the variance cover (Table 3).
Table 3: Total variance explained by the ten extracted factors
of the ATTS scale
Component
Initial Eigenvalues
Extraction Sums of Squared
Loadings
Total
% of
Variance
Cumulative
%
Total
% of
Variance
Cumulati
ve %
1
6.175
61.746
61.746
6.175
61.746
61.746
2
1.480
14.798
76.544
1.480
14.798
76.544
3
.716
7.158
83.701
4
.398
3.977
87.679
5
.309
3.088
90.767
6
.260
2.602
93.368
7
.231
2.314
95.683
8
.171
1.707
97.390
9
.156
1.564
98.954
10
.105
1.046
100.000
The responses to the items of FAS are shown
in (Table 4).
Table 4: Subscale factors loading scores and loading of items
that exceed 0.30
Items
F1
F2
Physical Fatigue
I am bothered by fatigue
0.880
I get tired very quickly
0.860
I don’t do much during the day
0.880
I have enough energy for everyday life
0.717
Physically, I feel exhausted
0.840
I have problems to start things
0.817
Mental Fatigue
I have problems to think clearly
I feel no desire to do anything
Mentally, I feel exhausted
When I am doing something, I can
concentrate quite well
0.888
0.742
0.916
0.696
Depending on the cut-off point identified in
other studies [19], people with a mean score of 22 or
above were experiencing major fatigue. According to
this cutoff point, 84 (74%) of the patients were
suffering from fatigue. Among males 54 (77.1%) and
in females, 30 (70%) were suffering from fatigue.
Given that the presence of items 4 and 10
reduces Cronbach’s alpha, we performed a separate
factor analysis after removing these two items, which
resulted in two subscales with a variance of 83.119.
Physical fatigue subscales included the items one to
six, and mental fatigue subscales consisted of items
number 7, 8 and 9 (Table 5). The internal consistency
calculation revealed that the alpha value of the whole
instrument after dropping item 4 and 10 was 0.927. An
alpha value of the physical fatigue and mental fatigue
was 0.945 and 0.896, respectively.
Table 5: Subscale factor loading scores and loading of items
that exceed 0.30 after eliminating item 4 and 10
Items
F1
F2
Physical Fatigue
I am bothered by fatigue
0.891
I get tired very quickly
0.865
I don`t do much during the day
0.887
Physically, I feel exhausted
0.847
I have problems to start things
0.838
Mental Fatigue
I have problems to think clearly
0.911
I feel no desire to do anything
0.746
Mentally, I feel exhausted
0.921
Lookzadeh et al. Evaluation of the Reliability and Validity of the Persian Version of the Fatigue Assessment Scale
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Discussion
This was the first study that translated the
FAS questionnaire into Persian and analysed its
reliability and validity among sarcoidosis patients in
Iran. Previous studies have suggested that FAS is
reliable and reliable in measuring fatigue in patients
with sarcoidosis [19]. This study showed that FAS
questionnaire was very practical and because of its
brief and usefulness, none of the patients refused to
continue during the study. At the time of responding to
the questionnaire, they answered the questionnaire
completely. In the present study, the two sexes did not
differ regarding fatigue, and this contradicts the results
of some studies [20]. Some studies have shown a
positive effect of age on fatigue [17], while others
have shown the opposite [18] [19] [20]. Unlike some
studies, two factors were extracted based on three
creatures.
Contrary to some studies, in the present
study, based on three Indicators of Scree plot,
Eigenvalue and total variance, two factors resulted in
[21] [22] [23] [24] [25]. In the current study, two
physical and mental factors of fatigue with the
coverage of over 70% and total variance of more than
70 were extracted. In this study, the Cronbach's alpha
coefficient in the case of reversal of questions 4 and
10 was 0.76. Without reversing these two questions,
this coefficient increased to 0.93, and when these two
questions were eliminated, 0.927 was obtained as the
Cronbach's alpha coefficient. The current study
showed that by removing these two questions or
adding them without reversing them, this
questionnaire has more comprehensive capabilities
and can be independently used to evaluate fatigue
score in sarcoidosis patients. A previous study
showed that the FAS questionnaire without questions
4 and 10 was superior to the FAS with these two
questions [26]. The previous studies also showed that
these two questions were unreliable [27] [28] [29]. We
also concluded that the existence of these two
questions in the questionnaire reduces the continuity
of the questions, and therefore we propose the FAS
questionnaire without the two questions 4 and 10. The
reason why these two questions are not reliable could
be that patients who fill out the questionnaire will rate
the two questions alike. Therefore, it can be
concluded that the FAS questionnaire has a high
alpha coefficient without reversing or eliminating
questions 4 and 10. The findings show that the
Persian language FAS questionnaire with inverse
questions 4 and 10, despite the low internal
communication (0.75), can assess fatigue in patients
with sarcoidosis.
In conclusion, we suggest that the Persian
language FAS questionnaire can be included as a
practical, easy and reliable method for assessing
fatigue involvement in routine check-ups of patients
with sarcoidosis. However, further studies with
applying inversed questions four and 10 in Persian
FAS questionnaire would be necessary to elucidate
the exact magnitude of the prevalence of fatigue in
sarcoidosis patients in Iran.
Acknowledgement
The authors would like to thank all the
hospital cooperators for their favour in conducting
current study.
Author contributions
Literature search: Somayeh Lookzadeh, Arda
Kiani, Kimia Taghavi, Shirin Kianersi, Habib Emami,
Maryam mienayat, Atefeh Abedini. Data collection:
Somayeh Lookzadeh, Kimia Taghavi, Shirin Kianersi,
Atefeh Abedini. Study design: Somayeh Lookzadeh,
Arda Kiani, Kimia Taghavi, Shirin Kianersi, Habib
Emami, Maryam mienayat, Atefeh Abedini. Data
analysis: Somayeh Lookzadeh, Shirin Kianersi, Habib
Emami. Manuscript preparation: Somayeh
Lookzadeh, Kimia Taghavi. Manuscript review:
Somayeh Lookzadeh, Arda Kiani, Kimia Taghavi,
Shirin Kianersi, Habib Emami, Maryam mienayat,
Atefeh Abedini.
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... Fatigue is also a highly prevalent condition that has been studied in a large number of patient populations with pathologies such as cancer [4][5][6], heart attack [7][8][9][10][11], kidney disease [12] or sarcoidosis [13][14][15][16], but also during pregnancy and the postpartum period [17][18][19], as well as in work environments [20][21][22][23]. ...
... With respect to the first hypothesis, the confirmatory factor analysis showed adequate fit indices for the one-dimensional structure, in line with the original instrument [1,29], as well as its validity in different populations [17,18,63]. However, it is worth noting that certain versions of the FAS have a two-dimensional structure, distinguishing between both the mental and the physical components of fatigue [10,16,17]. To be specific, Giallo et al. [17] showed a good data fit for both the one-dimensional and two-dimensional structures. ...
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Symptoms of fatigue and lack of energy are very common in caregivers of palliative care (PC) patients, traditionally associated with variables such as burden or depression. There are no Spanish-language instruments validated for assessing fatigue levels in this population. The Fatigue Assessment Scale (FAS) is a useful and simple instrument for assessing fatigue in this group. The aim of this study was to examine its psychometric properties (factor structure, reliability and validity) in a sample of caregivers of PC patients. Instrumental design for instrument validation was performed. One hundred and eight caregivers of PC patients participated and completed measures of fatigue, family functioning, life satisfaction, caregiver burden, anxiety, depression, resilience and quality of life. A confirmatory factor analysis was performed; non-linear reliability coefficient and Pearson correlations and t-tests were conducted to assess evidence of reliability and validity. The Spanish version of the FAS was found to have a one-dimensional structure. Reliability was 0.88. Validity evidence showed that FAS scores were positively associated with levels of burden, anxiety and depression. They were negatively associated with family functioning, life satisfaction, resilience and quality of life. The Spanish version of the FAS in caregivers of PC patients shows adequate psychometric properties.
... The cut-off point for fatigue in stroke patients was set at 24 based on the FAS [30]. As to internal consistency of the Persian ver-sion, Cronbach's alpha coefficient for physical and mental fatigue was 0.945 and 0.896, respectively [36,37]. ...
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Background: A major complication caused by stroke is poststroke fatigue (PSF), and by causing limitations in doing activities of daily living (ADL), it can lower the quality of life. Objective: The present study is an attempt to examine the effects of vestibular rehabilitation on BADL (Basic Activities of Daily Living), fatigue, depression, and Lawton Instrumental Activities of Daily Living (IADL) in patients with stroke. Method: Patients with a history of stroke took part voluntarily in a single-blind clinical trial. The participants were allocated to control and experimental groups randomly. The experimental group attended 24 sessions of vestibular rehabilitation protocol, while the control group received the standard rehabilitation (including three sessions per week each for around 60 min). To measure fatigue, the Fatigue Impact Scale (FIS) and the Fatigue Assessment Scale (FAS) were used. Depression, BADL, and IADL were measured using the Beck Depression Inventory-II (BDI-II), Barthel Index (BI), and Lawton Instrumental Activities of Daily Living, respectively. All changes were measured from the baseline after the intervention. Results: Significant improvement was found in the experimental group compared to the control group (p < 0.05) in FIS (physical, cognition, and social subscales), FAS, BDI-II, BADL, and IADL. Moreover, the results showed small to medium and large effect sizes for the physical subscale of FIS and FAS scores based on Cohen's d, respectively; however, no significant difference was found in terms of cognition and social subscales of FIS, BDI-II, BADL, and IADL scores. Conclusion: It is possible to improve fatigue, depression, and independence in BADL and IADL using vestibular rehabilitation. Thus, it is an effective intervention in case of stroke, which is also well tolerated.
... Except for statements 4 (I have enough energy for everyday life) and 10 (When I am doing something, I can concentrate quite well), the remaining 8 statements are negative. Thus, the scores of the options chosen for statements 4 and 10 are reversed before the analysis of the data ("1 = always" and "5 = never") (21,22). ...
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Objective: The purpose of this study is to compare the levels of physical activity, fatigue, and quality of life of healthy individuals belonging to different age groups. Methods: A total of 107 healthy individuals participated in the study, of which 39 were young (aged between 18 and 39), 42 were middle-aged (aged between 40 and 64), and 26 were elderly (over 65 years old). While physical activity was measured using the International Physical Activity Questionnaire, fatigue level was evaluated using the Fatigue Assessment Scale, and quality of life with the World Health Organization Quality of Life Instruments. Results: A statistically significant difference has been detected between three groups with regards to the levels of physical activity, fatigue, and quality of life (p<0.05). The physical activity levels of the elderly individuals were lower than those of the middle-aged individuals, while their fatigue levels were higher. The quality of life which was related to physical health and social relationships of the young and the middle-aged were similar and higher than those of the elderly individuals. Middle-aged individuals had a higher psychological health-related quality of life than elderly individuals, but their environment-and physical health-related quality of life was higher than both young and elderly individuals. Conclusion: It has been concluded that elderly age group is associated with the lowest levels of physical activity and quality of life and the highest level of fatigue. We think that by getting elderly to adopt habit of exercise, the decrease in levels of physical activity and quality of life, and increase in fatigue level can be prevented.
... 9 Sarcoidosis is diagnosed in patients across the globe with variable incidences, prevalence and courses of disease among different regions and ethnicities. 10 Sarcoidosis in the Middle East was previously addressed in some studies from Saudi Arabia, [11][12][13] Kuwait, 14 Oman, 15 Turkey, 6,16 Israel, 17,18 Iran 19,20 and Egypt. 21,22 In this study, we aimed to evaluate the clinical phenotypic features of sarcoidosis in a single-center academic hospital in Jordan. ...
Article
Objectives: This study aims to evaluate the clinical phenotypic features of sarcoidosis in a single-center academic hospital in Jordan. Patients and methods: A retrospective file review was performed at an academic medical center in Jordan that included all patients diagnosed with sarcoidosis between January 2000 and December 2018. A total of 150 patients with sarcoidosis (38 males, 112 females; mean age 47.8±11.7 years; range, 17 to 79 years) were evaluated. Clinical data extracted from the files included the sex of the patient, the age at time of diagnosis, diagnosis date, the season during which the diagnosis was established, and smoking history. Biopsy histopathology, spirometry, nerve conduction, echocardiography, and imaging reports including plain radiographs, ultrasonographic, magnetic resonance and computed tomography reports were reviewed. Data including laboratory values, medication usage, clinical outcomes, and morbidity/mortality were collected. Pulmonary function tests including spirometry and lung volumes along with the diffusing capacity for carbon monoxide were reviewed for the presence of restriction, obstruction or reduction in the diffusion capacity of carbon monoxide. Identification of extra-thoracic organ involvement was determined in each patient in accordance with the criteria suggested by the updated World Association of Sarcoidosis and Other Granulomatous Disorders. Results: A total of 77.3% of the patients were diagnosed by biopsy. One case of Lofgren's syndrome was identified. Of the patients, 18.0% had isolated pulmonary sarcoidosis, 75.3% had pulmonary and extra-pulmonary sarcoidosis and 6.7% had isolated extra-pulmonary sarcoidosis while 81.3% had respiratory symptoms, mostly shortness of breath and cough. Extra-thoracic organ involvement mostly involved the musculoskeletal system (33%) followed by the skin (20%). Female patients had more extra-thoracic involvement but the sex difference was only statistically significant for cutaneous involvement. Of the patients, 84% received treatment while 20% had disease remission during the first two years after diagnosis and 70% required treatment beyond two years after diagnosis. Conclusion: Various sarcoidosis clinical phenotypes are seen among Jordanian patients. Jordanian females are more affected by the disease and have more extra-thoracic involvement compared to male patients. A large number of the study patients received treatment.
... 9 Sarcoidosis is diagnosed in patients across the globe with variable incidences, prevalence and courses of disease among different regions and ethnicities. 10 Sarcoidosis in the Middle East was previously addressed in some studies from Saudi Arabia, [11][12][13] Kuwait, 14 Oman, 15 Turkey, 6,16 Israel, 17,18 Iran 19,20 and Egypt. 21,22 In this study, we aimed to evaluate the clinical phenotypic features of sarcoidosis in a single-center academic hospital in Jordan. ...
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Objectives: This study aims to evaluate the clinical phenotypic features of sarcoidosis in a single-center academic hospital in Jordan. Patients and methods: A retrospective file review was performed at an academic medical center in Jordan that included all patients diagnosed with sarcoidosis between January 2000 and December 2018. A total of 150 patients with sarcoidosis (38 males, 112 females; mean age 47.8±11.7 years; range, 17 to 79 years) were evaluated. Clinical data extracted from the files included the sex of the patient, the age at time of diagnosis, diagnosis date, the season during which the diagnosis was established, and smoking history. Biopsy histopathology, spirometry, nerve conduction, echocardiography, and imaging reports including plain radiographs, ultrasonographic, magnetic resonance and computed tomography reports were reviewed. Data including laboratory values, medication usage, clinical outcomes, and morbidity/mortality were collected. Pulmonary function tests including spirometry and lung volumes along with the diffusing capacity for carbon monoxide were reviewed for the presence of restriction, obstruction or reduction in the diffusion capacity of carbon monoxide. Identification of extra-thoracic organ involvement was determined in each patient in accordance with the criteria suggested by the updated World Association of Sarcoidosis and Other Granulomatous Disorders. Results: A total of 77.3% of the patients were diagnosed by biopsy. One case of Lofgren’s syndrome was identified. Of the patients, 18.0% had isolated pulmonary sarcoidosis, 75.3% had pulmonary and extra-pulmonary sarcoidosis and 6.7% had isolated extra-pulmonary sarcoidosis while 81.3% had respiratory symptoms, mostly shortness of breath and cough. Extra-thoracic organ involvement mostly involved the musculoskeletal system (33%) followed by the skin (20%). Female patients had more extra-thoracic involvement but the sex difference was only statistically significant for cutaneous involvement. Of the patients, 84% received treatment while 20% had disease remission during the first two years after diagnosis and 70% required treatment beyond two years after diagnosis. Conclusion: Various sarcoidosis clinical phenotypes are seen among Jordanian patients. Jordanian females are more affected by the disease and have more extra-thoracic involvement compared to male patients. A large number of the study patients received treatment. Keywords: Arab, Jordan, sarcoidosis, World Association of Sarcoidosis and Other Granulomatous Disorders
Article
Health-related quality of life (HRQoL) describes an individual's perception of the impact of health, disease, and treatment on their quality of life (QoL). It is a reflection of how the manifestation of an illness and its treatment is personally experienced. Assessing HRQoL is particularly important in sarcoidosis because the attributable disease mortality is relatively low, and one of the major reasons for initiating treatment is to improve quality of life. HRQoL has been assessed in sarcoidosis using various generic and sarcoid-specific patient-reported outcome measures (PROMs). It is important that both the direct and indirect effects of the disease, as well as potential toxicities of therapy, are captured in the various PROMs used to assess HRQoL in sarcoidosis. This article provides a general overview of HRQoL in patients with sarcoidosis. It describes the various PROMs used to assess HRQoL in sarcoidosis and addresses the various factors that influence HRQoL in sarcoidosis. Specific attention is paid to fatigue, small fiber neuropathy, corticosteroid therapy, and other disease-specific factors that affect HRQoL in sarcoidosis. It also provides an insight into interventions that have been associated with improved HRQoL in sarcoidosis and offers suggestions for future research in this important area.
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Introduction Fatigue is a frequent and troublesome manifestation of chronic sarcoidosis. This symptom can be debilitating and difficult to treat, with poor response to the treatment. Symptomatic management with neurostimulants, such as methylphenidate, is a possible treatment option. The use of such treatment strategies is not without precedent and has been trialled in cancer-related fatigue. Their use in sarcoidosis requires further evaluation before it can be recommended for clinical practice. Methods and analysis The Fatigue and Sarcoidosis—Treatment with Methylphenidate study is a randomised, controlled, parallel-arm and feasibility trial of methylphenidate for the treatment of sarcoidosis-associated fatigue. Patients are eligible if they have a diagnosis of sarcoidosis, significant fatigue (measured using the Fatigue Assessment Scale) and have stable disease. Up to 30 participants will be randomly assigned to either methylphenidate (20 mg two times per day) or identical placebo in a 3:2 ratio for 24 weeks. The primary objective is to collect data determining the feasibility of a future study powered to determine the clinical efficacy of methylphenidate for sarcoidosis-associated fatigue. The trial is presently open and will continue until July 2018. Ethics and dissemination Ethical approval for the study was granted by the Cambridge Central Research Ethics Committee on 21 June 2016 (reference 16/EE/0087) and was approved and sponsored by the Norfolk and Norwich University Hospital (reference 190280). Clinical Trial Authorisation (EudraCT number 2016-000342-60) from the Medicines and Healthcare products Regulatory Agency (MHRA) was granted on 19 April 2016. Results will be presented at relevant conferences and submitted to appropriate journals following trial closure and analysis. Trial registration number NCT02643732; Pre-results.
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Background: Little is known about physical activity in daily life among patients with sarcoidosis. Fatigue is a frequent and disabling symptom that might negatively affect physical activity levels. Methods: In patients with sarcoidosis, we measured physical activity (steps per day) by accelerometry (SenseWear Armband) for 1 week. We assessed lung function (DLCO, FVC), exercise capacity (6-min walking distance [6MWD]), health-related quality of life (St George's Respiratory Questionnaire [SGRQ]), generic quality of life (12-Item Short-Form Health Survey [SF-12]), and fatigue (Multidimensional Fatigue Inventory [MFI-20]). Results: We investigated 57 patients with sarcoidosis (mean age 50 years, 56% male, mean DLCO 73% predicted, mean FVC 91% predicted, mean 6MWD 525 m, mean steps per day 7,490), of whom n = 14 (25%) had severe fatigue. The MFI-20 subscales "reduced activity" and "physical fatigue" were weakly associated with steps per day on a bivariate level (Spearman ρ = -0.274 and ρ = -0.277, respectively; p < 0.05), while the other subscales and the total score were not. 6MWD, SGRQ score, and SF-12 (physical health) score showed stronger associations with steps per day in bivariate analyses (Pearson r = 0.499, r = -0.386, and r = 0.467, respectively; p < 0.01), and were independent predictors of steps per day in multivariate linear regression analyses adjusting for confounders (p < 0.05). In ROC curve analyses, 6MWD, SGRQ score, and SF-12 (physical health) score properly identified sedentary patients (steps per day <5,000; AUROC 0.90, 0.81, and 0.80, respectively; p < 0.01). Fatigue was less predictive (MFI-20 subscale "general fatigue," AUROC 0.70; p = 0.03). Conclusion: While exercise capacity and quality of life measurements were robust predictors of physical activity in patients with sarcoidosis, associations of objectively measured physical activity with fatigue were surprisingly weak. In sarcoidosis, fatigue might not preclude affected patients from being physically active, although this symptom is subjectively perceived as highly disabling.
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Background Fatigue is the most widely reported symptom by women during pregnancy, labour, the postpartum period, and early parenting. The objective was to translate the Fatigue Assessment Scale (FAS) into Spanish and assess its psychometric properties. Methods Instrumental Design. The FAS was translated into Spanish (FAS-e) using forward and back translation. A convenience sample was constituted with 870 postpartum women recruited at discharge from 17 public hospitals in Eastern Spain. Data was obtained from clinical records and self-administered questionnaires at discharge. Internal consistency, factor structure, comparisons between known groups and correlations with other variables were assessed. Results Cronbach’s alpha coefficient was .80. Findings on the dimensionality of the FAS-e scale indicated that it was sufficiently unidimensional. FAS-e scores were higher among women who had undergone caesarean births ( p < .05), had a higher level of postpartum pain ( p < .01), experienced difficulties during breastfeeding ( p < .01) and had lower levels of self-efficacy for breastfeeding ( p < .01). Conclusions An equivalent Spanish version of the FAS was obtained with good reliability and validity properties. FAS-e is an appropriate tool to measure postpartum fatigue.
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Background Despite negative association between 25-hydroxy vitamin D and incidence of many chronic respiratory diseases, this feature was not well studied in sarcoidosis. Current study investigated the association between 25-hydroxy vitamin D deficiency with sarcoidosis chronicity, disease activity, extra-pulmonary skin manifestations, urine calcium level and pulmonary function status in Iranian sarcoidosis patients. Results of this study along with future studies, will supply more effective programs for sarcoidosis treatment. Methods Eighty sarcoidosis patients in two groups of insufficient serum level and sufficient serum level of 25-hydroxy vitamin D were studied. Course of sarcoidosis was defined as acute and chronic sarcoidosis. Pulmonary function test (PFT) was assessed by spirometry. Skin involvements were defined as biopsy proven skin sarcoidosis. 24-hour urine calcium level was used to specify the disease activity. Stages of lung involvements were obtained by CT-scan and chest X-ray. The statistical analyses were evaluated using Statistical Package for the Social Sciences. Results A significant negative correlation was obtained between vitamin D deficiency in sarcoidosis patients and disease chronic course and stages two to four of lung involvements. Considering other parameters of the disease and vitamin D deficiency, no significant correlation was detected. Conclusions In conclusion, results of the current study implies in the role of vitamin 25(OH)D deficiencies in predicting the course of chronic sarcoidosis. Furthermore, it was concluded that vitamin 25(OH)D deficiency can direct pulmonary sarcoidosis toward stage 2–4 of lung involvements.
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Background: This study aimed to investigate the epidemiological characteristics of pulmonary tuberculosis (TB) in Heilongjiang province from 2008 to 2015 and provide scientific basis for the development of TB control. Methods: The TB patients were confirmed by chest radiography and sputum examination, and the TB incidence data were from the Chinese Tuberculosis Management Information System, population data were from the National Basic Information System. Results: By the SPSS statistics analysis, there was a total of 280,767 cases of TB registered in Heilongjiang province from 2008 to 2015; the average annual incidence rate was 91.60/100,000, the male incidence rate was 122.81/100,000; the female incidence rate was 59.39/100,000, and TB incidence increased as the growth of age. Farmers' incidence was higher than other occupations; Shuangyashan city incidence of 122.09/100,000 was highest during 13 cities in Heilongjiang province, all above factors existed significant difference. Conclusions: As a result, TB incidence was higher among the elderly, males and farmers, so it is important to promote the scientific knowledge about the prevention and treatment of TB. In particular, it is necessary to strengthen the health education of the elder aged people and improve the self-care awareness and ability to prevent TB.
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Background: Health-care workers (HCWs) are at increased risk of acquiring tuberculosis (TB) than the general population. While national-level data on the burden of TB in general population is available from reliable sources, nationally representative data on latent tuberculosis infection (LTBI) burden in HCWs in the high burden countries is lacking. Methods: A prospective study was carried out to assess the risk of TB infection among HCWs who directly engage in medical duties. HCWs were recruited between January 2014 and December 2015. A structured questionnaire was used for risk assessment of TB infection among HCWs, including sociodemographic characteristics (e.g., age, gender, period of professional work, and employed position), knowledge of TB prevention and control, and history of professional work. A single-step tuberculin skin test (TST) using 5 international units (IU; 0.1 ml) of tuberculin (purified protein derivative from Mycobacterium bovis Bacillus Calmette-Guérin [BCG]). TB infection was determined using a TST induration ≥10 mm as a cutoff point for TST positivity. TST-positive participants were further subjected to detailed clinical evaluation and chest radiography to rule out active TB. The associations between TB infection and the sociodemographic characteristics, duration of possible exposure to TB while on medical duties, BCG vaccination, and knowledge about TB were estimated using Chi-square test. A two-sided P < 0.05 indicated statistical significance. Results: A total of 206 eligible HCWs signed the informed consent and completed the questionnaires between January 2014 and December 2015. The age of the participants ranged from 18 to 71 years, with a mean age of 27.13 years. TST induration size (mean 6.37 mm) the TST results suggested that 36.8% (76/206) were infected with TB using a TST induration ≥10 mm as a cut-off point. All 76 TST-positive HCWs showed no evidence of active TB in clinical evaluation and chest radiography. However, during the study, two HCWs developed pulmonary TB (both TST baseline test negative). Statistical analysis suggested that age, duration of employment as a health-care professional, literacy status, and working in medical wards/OP/Intensive Care Unit were significantly associated with TB infection. Conclusions: Many studies propose serial tests of LTBI as effective occupational protection strategies. However, practically, it is not feasible because it has to be done at frequent intervals, but how frequently to be done is not clear. Another concern is even if found to have LTBI, there are no clear consensus guidelines about the treatment in high prevalence settings. The prevalence of LTBI is so high in countries like India that affected HCWs could not be exempted from working in high-risk areas. The depth of knowledge of TB prevention and control among HCWs should be improved by regular infection control training.
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Background: There is growing evidence that emotional distress expressed in terms of anxiety and depression it is very high among tuberculosis (TB) patients. Objectives: This study aims to determine levels of anxiety, depression and emotional distress in patients with several types of TB and to determine the association between social-demographic and economical factors, clinical variables and anxiety, depression and emotional distress. Methods: A cross-sectional study was performed in a sample of 81 TB patients. A social-demographic and economical questionnaire was used, followed by the Hospital Anxiety and Depression Scale. Results: 38.3% and 49.4% of our sample presented significant levels of anxiety and depression. 44.4% of patients had significant levels of emotional distress. Married subjects, a diagnosis of extra-pulmonary TB and multidrug resistant TB were related to higher risk for anxiety. Gender, extra-pulmonary and multidrug resistant TB were associated to depression. Female gender and cases of extra-pulmonary TB presented a 1,5 times risk for emotional distress. Conclusions: Our study found high rates of anxiety, depression and emotional distress among TB patients. Marital status, gender, type and treatment of TB were related to higher levels of emotional disorder. Mental health services should be an integral part of programs against tuberculosis.
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Objective/background: The histological diagnosis of Mycobacterium tuberculosis (MTB) has long been a diagnostic challenge in the anatomical pathology field despite availability of different laboratory methods. Immunohistochemistry (IHC) could not only confirm granulomatous tissue involvement but also demonstrate MTB antigen immunolocalization. This study tries to clarify the details of IHC staining for MTB with pAbBCG. Methods: A total of 50 patients undergoing simultaneous biopsy and tissue culture with positive tissue culture for MTB during 2005-2009 were selected from the MRC Department at Masih Daneshvari Hospital, Tehran, Iran. Using the archives of the Pathology Department of this hospital, which is a referral center for pathological lung lesions, hematoxylin and eosin slides of the selected patients were evaluated. Twenty-three confirmed TB granulomatous tissue samples with adequate tissue and number of granulomas were chosen and studied by Ziehl-Neelsen and IHC staining with pAbBCG. Results: A total of 23 cases were evaluated, of which 17 (73.9%) were males. The types of tissue obtained from study cases were as follows: pleura (9 cases, 39.1%), lymph node (cervical, axillary, and thoracic [9 cases, 39.1%]), and lung tissues (5 cases, 21.7%). IHC staining was positive in all samples, whereas Ziehl-Neelsen staining was positive in nine cases of 23 (39.1%). IHC showed positive coarse granular cytoplasmic and round, fragmented bacillary staining. In this study, epithelioid cells clearly showed more positive staining at the periphery rather than at the center of granuloma. There is also positive staining in endothelial cells, fibroblasts, plasma cells, macrophages, and lymphocytes outside the granuloma. Conclusion: Detection of TB in tissue slides is still based on the histological pattern of the granuloma, which has several differential diagnoses with different treatments. Presence of mycobacterial antigens and tissue morphology can be evaluated using the IHC technique. Considering the criteria of positive IHC staining of TB granulomatous reactions, this stain not only highlights the presence of mycobacterial antigens for tissue diagnosis, but also could morphologically localize their distribution in different cells. Pathologists must be familiar with adequate staining pattern, elimination of background staining, and type of selected antibody. This method is especially important for application in countries with high prevalence of TB as a technique with early diagnostic value in tissue specimens. Early diagnosis using this technique can reduce related morbidity and mortality and decrease the rate of complications due to misdiagnosis and mistreatment of TB.
Article
Chronic fatigue syndrome (CFS) is a heterogeneous disease which presents with pronounced disabling fatigue, sleep disturbances, and cognitive impairment that negatively affects patients’ functional capability. CFS remains a poorly defined entity and its etiology is still in question. CFS is neither a novel diagnosis nor a new medical condition. From as early as the eighteenth century, a constellation of perplexing symptoms was observed that resembled symptoms of CFS. Commencing with “febricula” and ending with CFS, many names for the disease were proposed including neurocirculatory asthenia, atypical poliomyelitis, Royal Free disease, effort syndrome, Akureyri disease, Tapanui disease, chronic Epstein-Barr virus syndrome, and myalgic encephalitis. To date, it remains unclear whether CFS has an autoimmune component or is a condition that precedes a full-blown autoimmune disease. Research suggests that CFS may overlap with other diseases including postural orthostatic tachycardia syndrome (POTS), autoimmune syndrome induced by adjuvants (ASIA), and Sjögren’s syndrome. Additionally, it has been postulated that the earliest manifestations of some autoimmune diseases can present with vague non-specific symptoms similar to CFS. Sometimes only when exposed to a secondary stimulus (e.g., antigen) which could accelerate the natural course of the disease would an individual develop the classic autoimmune disease. Due to the similarity of symptoms, it has been postulated that CFS could simply be an early manifestation of an autoimmune disease. This paper will provide a historical background review of this disease and a discussion of CFS as an entity overlapping with multiple other conditions.
Article
Background: Fatigue is common among patients with sarcoidosis. The etiology of this problem is unknown and multifactorial. Fatigue can be confounded with excessive daytime sleepiness (EDS). Fatigue and sleepiness have rarely been studied simultaneously in sarcoidosis patients. Objectives: The aim of this study was the confounder-adjusted estimation of risks for severe fatigue and EDS in a large population of sarcoidosis patients and the development of multivariate predictors from this population. Methods: 1,197 German sarcoidosis patients were examined using the Epworth Sleepiness Scale (ESS), the Fatigue Assessment Scale (FAS), the Hospital Anxiety and Depression Scale (HADS), and the Medical Research Council (MRC) dyspnea scale. Results: 16.5% (123 patients) had EDS (ESS ≥16), 16.4% had severe fatigue (FAS ≥35), and 6.3% had both extreme findings. In a multivariate logistic regression model, predictors of the risk of EDS were a history of sleep apnea (odds ratio [OR] 2.46, 95% confidence interval [CI] 1.5-3.9), dyspnea MRC grade ≥2 (OR 2.29, 95% CI 1.5-3.5), and organ involvement of 4-7 organs (OR 1.60, 95% CI 1.1-2.4). Significantly associated with higher risk of severe fatigue were the following: conspicuous depression (OR 5.95, 95% CI 4.1-8.7), conspicuous anxiety (OR 2.38, 95% CI 1.6-3.4), and muscle pain (OR 1.92, 95% CI 1.32-2.75). The logit models for severe fatigue with and without simultaneous EDS differed only slightly. Conclusion: An extreme form of fatigue and/or sleepiness was found in 27% of all sarcoidosis patients questioned. Because there is a certain overlap, both should be examined simultaneously to allow for a combined assessment.