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know about other existing diseases and apply it to the problems suffered by Gulf War veterans.

In extrapolating from specific clinical entities to the problems of Gulf War veterans, the committee chose to recommend only those specific therapies for which efficacy has been demonstrated through one or more randomized controlled trials. However, there may be situations where other approaches are used to manage these conditions. Some of these approaches are described in the “Practice Issue” sections included with each condition. While the committee has chosen to recommend only those therapies whose efficacy has been demonstrated through randomized controlled trials (RCTs), it is important to continue to evaluate these other therapies.

As indicated in Chapter 3, the committee believes that it is essential to demonstrate treatment effectiveness using other approaches to study design. The committee found, however, that there are essentially no strong effectiveness studies of treatments for the selected conditions. The best currently available evidence for potential effectiveness in a population of Gulf War veterans, therefore, is strong evidence of efficacy through RCTs.



Chronic fatigue syndrome (CFS) is a clinically defined condition characterized by severe, disabling fatigue that persists for at least six months and has a definite onset (Fukuda et al. 1994). Appendix C provides a discussion of unique considerations in CFS. The symptoms include self-reported problems in concentration, short-term memory, sleep, and musculoskeletal pain. A diagnosis is made only after alternative medical and psychiatric causes of fatiguing illness are excluded. There are no laboratory tests that can confirm its diagnosis, no pathognomonic physical examination findings, and no treatment that alleviates the symptoms for all patients (Buchwald and Komaroff 1991; Komaroff and Buchwald 1991, 1998). A major question regarding the diagnosis of CFS is whether it is a discrete entity as opposed to the most severe manifestation of a spectrum of fatigue, or a debilitating but nonspecific symptom complex shared by many different clinical entities.

No single cause of CFS has been identified, but many avenues of investigation have been undertaken. Since about 80% of patients diagnosed with CFS report that their condition started with a virus-like illness (Buchwald and Komaroff 1991; Komaroff and Buchwald 1991), infections were the focus of early studies. Over the last decade, many infectious agents have been suspected and investigated, including Epstein-Barr virus, but none has been found to be causative for CFS (Buchwald et al.

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