What are the key symptoms of Chronic Fatigue Syndrome. How is CFS diagnosed. What are the most effective treatments for managing CFS. Can lifestyle changes help alleviate CFS symptoms. Are there any promising new therapies for Chronic Fatigue Syndrome.

Understanding Chronic Fatigue Syndrome: A Complex and Debilitating Condition

Chronic Fatigue Syndrome (CFS), also known as Myalgic Encephalomyelitis (ME), is a complex and often misunderstood condition that affects millions of people worldwide. Characterized by severe, persistent fatigue that is not alleviated by rest, CFS can have a profound impact on a person’s quality of life and ability to function in daily activities.

The Centers for Disease Control and Prevention (CDC) estimates that more than 2 million Americans suffer from CFS, with many cases remaining undiagnosed. Women are twice as likely as men to develop the condition, and it is more prevalent in individuals over the age of 40. The economic impact of CFS is substantial, with estimated annual productivity losses in the United States reaching $9.1 billion as of 2002.

Recognizing the Symptoms: Key Indicators of Chronic Fatigue Syndrome

Identifying CFS can be challenging due to its diverse range of symptoms and the absence of a specific diagnostic test. However, the CDC has established criteria to aid in diagnosis. The primary symptoms of CFS include:

• Severe fatigue lasting longer than six months
• Post-exertional malaise (worsening of symptoms after physical or mental exertion)
• Unrefreshing sleep
• Cognitive impairment (often referred to as “brain fog”)
• Muscle pain
• Joint pain without swelling or redness
• Headaches of a new type, pattern, or severity
• Sore throat
• Tender lymph nodes

To meet the CDC criteria for CFS, an individual must experience severe fatigue for at least six months and exhibit at least four of the additional symptoms listed above.

Diagnosing CFS: A Process of Exclusion and Careful Evaluation

Diagnosing Chronic Fatigue Syndrome is a complex process that involves ruling out other potential causes of fatigue. There is no single test that can definitively diagnose CFS, making it a diagnosis of exclusion. Healthcare providers typically follow these steps:

1. Comprehensive medical history and physical examination
2. Laboratory tests to rule out other conditions (e.g., thyroid disorders, anemia, autoimmune diseases)
3. Evaluation of symptoms against established diagnostic criteria
4. Assessment of functional impairment and impact on daily life

Is there a specific set of tests for diagnosing CFS? While there is no definitive diagnostic test for CFS, healthcare providers often perform a range of tests to exclude other conditions. These may include:

• Complete blood count (CBC)
• Comprehensive metabolic panel
• Thyroid function tests
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP) levels
• Urinalysis

Exploring the Etiology: Potential Causes and Risk Factors of CFS

The exact cause of Chronic Fatigue Syndrome remains unclear, but researchers believe it likely involves a complex interplay of various factors. Some potential contributors to the development of CFS include:

• Immune system dysfunction
• Hormonal imbalances, particularly involving the hypothalamic-pituitary-adrenal (HPA) axis
• Viral infections (e.g., Epstein-Barr virus, human herpesvirus 6)
• Genetic predisposition
• Psychological stress and trauma
• Environmental factors

Does a history of childhood trauma increase the risk of developing CFS? Some studies have suggested a potential link between childhood trauma and an increased risk of CFS in adulthood. While the exact mechanism is not fully understood, it is believed that early life stress may alter the body’s stress response systems, potentially contributing to the development of CFS later in life.

Treatment Approaches: Managing Symptoms and Improving Quality of Life

While there is no cure for Chronic Fatigue Syndrome, various treatment approaches can help manage symptoms and improve overall quality of life. The most effective treatments typically involve a multidisciplinary approach, combining different strategies tailored to the individual’s specific needs.

Evidence-Based Therapies

Two treatments have shown moderate effectiveness in improving fatigue levels, work and social adjustment, anxiety, and post-exertional malaise in CFS patients:

1. Cognitive Behavioral Therapy (CBT): This psychological intervention helps patients identify and modify thought patterns and behaviors that may be exacerbating their symptoms.
2. Graded Exercise Therapy (GET): A structured exercise program that gradually increases the duration and intensity of physical activity, tailored to the patient’s capabilities.

How effective are CBT and GET in treating CFS? While not a cure, both CBT and GET have been shown to moderately improve symptoms in many CFS patients. A systematic review of randomized controlled trials found that these therapies can lead to significant improvements in fatigue levels, functional capacity, and quality of life for some individuals with CFS.

Pharmacological Interventions

Currently, there are no FDA-approved medications specifically for treating CFS. However, healthcare providers may prescribe medications to address specific symptoms or comorbid conditions, such as:

• Pain relievers for muscle and joint pain
• Antidepressants for mood disorders or to improve sleep quality
• Sleep aids for insomnia
• Anti-anxiety medications for managing stress and anxiety

Lifestyle Modifications: Supporting Overall Health and Symptom Management

In addition to medical treatments, lifestyle modifications can play a crucial role in managing CFS symptoms and improving overall well-being. Some key strategies include:

• Pacing activities to avoid overexertion
• Maintaining a consistent sleep schedule
• Practicing stress-reduction techniques (e.g., meditation, deep breathing exercises)
• Following a balanced, nutrient-rich diet
• Staying hydrated
• Avoiding caffeine, alcohol, and nicotine
• Creating a supportive environment at home and work

Can dietary changes help alleviate CFS symptoms? While there is no specific diet proven to cure CFS, some patients report improvements in their symptoms by following an anti-inflammatory diet or identifying and eliminating food sensitivities. It’s important to work with a healthcare provider or registered dietitian to ensure any dietary changes are safe and appropriate for individual needs.

Emerging Research and Future Directions in CFS Treatment

As our understanding of Chronic Fatigue Syndrome continues to evolve, researchers are exploring new potential treatments and diagnostic tools. Some promising areas of investigation include:

• Immunomodulatory therapies to address potential immune system dysfunction
• Mitochondrial function support to improve energy production at the cellular level
• Gut microbiome interventions to address potential links between gut health and CFS symptoms
• Novel biomarkers for improved diagnosis and treatment monitoring
• Personalized medicine approaches to tailor treatments based on individual genetic and metabolic profiles

Are there any promising new therapies on the horizon for CFS? While research is ongoing, several potential therapies are being investigated, including rituximab (an immunosuppressant), low-dose naltrexone, and various antiviral medications. However, it’s important to note that these treatments are still experimental and require further study to determine their safety and efficacy in treating CFS.

Living with CFS: Coping Strategies and Support Systems

Chronic Fatigue Syndrome can be a challenging and often isolating condition. Developing effective coping strategies and building a strong support system are crucial for maintaining mental health and overall well-being. Some helpful approaches include:

• Joining support groups or online communities for individuals with CFS
• Educating friends, family, and employers about the condition
• Exploring adaptive technologies and tools to assist with daily tasks
• Practicing self-compassion and setting realistic expectations
• Engaging in enjoyable, low-energy activities to maintain a sense of purpose and fulfillment
• Seeking professional counseling or therapy to address emotional challenges

How can family members and friends best support someone with CFS? Supporting a loved one with CFS involves understanding the unpredictable nature of the condition, offering practical assistance with daily tasks, and providing emotional support without judgment. Educating oneself about CFS and maintaining open communication can help foster a supportive environment for individuals living with this challenging condition.

Chronic Fatigue Syndrome is a complex and debilitating condition that requires a comprehensive approach to diagnosis and management. While there is no cure, a combination of evidence-based treatments, lifestyle modifications, and ongoing support can help individuals with CFS improve their quality of life and better manage their symptoms. As research continues to advance our understanding of this condition, there is hope for more effective treatments and improved outcomes for those affected by CFS in the future.

Chronic Fatigue Syndrome: Diagnosis and Treatment

JOSEPH R. YANCEY, MD, AND SARAH M. THOMAS, MD

A more recent article on fatigue in adults is available.

Please note: This information was current at the time of publication but may now be out of date; an update on this topic is currently in progress.

Am Fam Physician. 2012;86(8):741-746

Related letter: Article on CFS Does Not Reflect Current Best Treatment Practices

Author disclosure: No relevant financial affiliations to disclose.

Chronic fatigue syndrome is characterized by debilitating fatigue that is not relieved with rest and is associated with physical symptoms. The Centers for Disease Control and Prevention criteria for chronic fatigue syndrome include severe fatigue lasting longer than six months, as well as presence of at least four of the following physical symptoms: postexertional malaise; unrefreshing sleep; impaired memory or concentration; muscle pain; polyarthralgia; sore throat; tender lymph nodes; or new headaches. It is a clinical diagnosis that can be made only when other disease processes are excluded. The etiology of chronic fatigue syndrome is unclear, is likely complex, and may involve dysfunction of the immune or adrenal systems, an association with certain genetic markers, or a history of childhood trauma. Persons with chronic fatigue syndrome should be evaluated for concurrent depression, pain, and sleep disturbances. Treatment options include cognitive behavior therapy and graded exercise therapy, both of which have been shown to moderately improve fatigue levels, work and social adjustment, anxiety, and postexertional malaise. No pharmacologic or alternative medicine therapies have been proven effective.

Chronic fatigue syndrome (CFS) is a widespread problem. It is estimated that more than 2 million Americans have CFS, many of whom have not been diagnosed.¹ Women are twice as likely as men to have CFS,¹ and it is more common in persons older than 40 years.^1,2 There is not an established racial or educational predilection.^1,2 CFS is often mentally and emotionally debilitating, and persons with this diagnosis are twice as likely to be unemployed as persons with fatigue who do not meet formal criteria for CFS.³ In 2002, the estimated annual cost of lost productivity was $9.1 billion dollars in the United States.⁴ In addition to economic hardships, persons with CFS are more likely to report subjective functional impairment than those with chronic fatigue. ³

Clinical recommendation	Evidence rating	References
Persons with chronic fatigue should have an evaluation, including history, physical examination, and initial laboratory testing (i.e., urinalysis; complete blood count; comprehensive metabolic panel; and measurement of thyroid-stimulating hormone, C-reactive protein, and phosphorus levels).	C	7, 8
Persons diagnosed with chronic fatigue syndrome should be evaluated and treated for comorbidities, such as sleep disturbance, depression, and pain. Any comorbidity identified should be treated.	C	7, 8
Persons diagnosed with chronic fatigue syndrome should be treated with cognitive behavior therapy, graded exercise therapy, or both. Cognitive behavior therapy and graded exercise therapy have been shown to improve fatigue, work and social adjustment, anxiety, and postexertional malaise.	A	22, 23, 26, 28, 29

Diagnosis

CFS is a clinical diagnosis that can be made only when other etiologies of fatigue have been excluded. Specific diagnostic criteria for CFS were developed by the Centers for Disease Control and Prevention (CDC) in 1988.⁵ During this time, it was theorized that viral illness was the primary etiology of CFS; therefore, the criteria focused on physical symptoms. To parallel the World Health Organization categorization of CFS as a neurologic disorder, the Oxford criteria were developed in 1991 (Table 1).⁶ These criteria emphasize mental fatigue over physical symptoms.⁶ The CDC’s criteria were revised in 1994 to broaden the definition, and at this time, are the most widely accepted diagnostic criteria for CFS (Table 2). ⁷

The general approach to a patient with chronic fatigue should start with a history and physical examination, focusing on identifying the most bothersome symptoms and red flag symptoms (Table 3) that may indicate a more serious underlying illness based on the National Institute for Health and Clinical Excellence (NICE) guidelines. ⁸ Patients should have a mental status examination, including evaluation for depression, which is present in 39 to 47 percent of patients with CFS.^3,9 Although the differential diagnosis for patients presenting with chronic fatigue is broad (Table 4), approximately one-third meet the criteria for CFS.³ No laboratory tests can be used to diagnose CFS; instead, they are used to rule out other causes of fatigue that would preclude the diagnosis of CFS. The CDC and NICE recommend a minimal set of tests for patients presenting with chronic fatigue.^7,8

Red flags	Disease process indicated
Chest pain	Cardiac disease
Focal neurologic deficits	Central nervous system malignancy or abscess, multiple sclerosis
Inflammatory signs or joint pain	Autoimmune disease (e. g., rheumatoid arthritis, systemic lupus erythematosus)
Lymphadenopathy or weight loss	Malignancy
Shortness of breath	Pulmonary disease

The CDC recommends initial evaluation with urinalysis; complete blood count; comprehensive metabolic panel; and measurement of phosphorus, thyroid-stimulating hormone, and C-reactive protein. ⁷ NICE also recommends using immunoglobulin A endomysial antibodies to screen for celiac disease, and if indicated by the history or physical examination, urine drug screening, rheumatoid factor testing, and antinuclear antibody testing.⁸ Viral titers are not recommended unless the patient’s history is suggestive of an infectious process, because they do not confirm or eliminate the diagnosis of CFS.

Etiology

The etiology of CFS is unclear and is likely complex. It remains controversial whether there is a single etiology for CFS; there may be several poorly understood subsets of the illness, or there may be multiple factors that interact with each other. These complex factors, along with the numerous psychiatric comorbidities of CFS, have led some experts to question whether any organic etiology exists. Current research on CFS focuses on the immune and adrenal systems, genetics, the biopsychosocial model, and sleep and nutrition.

IMMUNE SYSTEM

Because many symptoms of viral infections and CFS overlap, some physicians have theorized that CFS has a postinfectious etiology. One popular theory is that CFS is caused by chronic Epstein-Barr virus infection; however, there is only mixed evidence of any association between specific viruses and CFS.¹⁰

GENETICS

Increasing evidence points to areas of genetic susceptibility in patients with CFS. One study found a difference in the expression of certain genes in patients with CFS after exercise that play a role in metabolism and immune responses.¹¹ Another study has shown an association between specific genetic mutations, CFS, and certain viral infections that have been linked to CFS.¹²

BIOPSYCHOSOCIAL MODEL

CFS is often associated with depression, which has led many physicians to believe that CFS is a purely somatic illness. Evidence supporting this conclusion is lacking. Strong evidence suggests that childhood trauma increases the risk of CFS by as much as sixfold. Some persons may assume that childhood trauma decreases resiliency, but there is evidence to suggest that it may also play an organic role by increasing the risk of adrenal system dysfunction. ¹³ It is important to note that social support systems for persons with CFS tend to be less reliable than for those who are healthy.¹⁴ Treatment for CFS is less likely to succeed in persons with poor social adjustment.¹⁵

ADRENAL SYSTEM

Hypocortisolism has been noted in persons with CFS; one study found cortisol levels in patients with CFS were about 5 mcg per dL (137.94 nmol per L) less than the levels in patients without CFS.¹⁶ This is likely secondary to impaired adrenal cortex responsiveness to adrenocorticotropic hormones and not to hypothalamopituitary dysfunction.¹⁷ It is unclear if such dysfunction is caused by infection, genetics, childhood trauma, unknown factors, or some combination of these.

SLEEP AND NUTRITION

There is an association between delayed dim light melatonin onset and CFS, suggesting that delayed circadian rhythm could contribute to CFS.¹⁸ Although melatonin is available over the counter for delayed dim light melatonin onset in the United States, there is no evidence for improvement in CFS with melatonin. ^18,19

One study has shown that persons with CFS have lower ratios of omega-3 to omega-6 unsaturated fatty acids and lower zinc levels than healthy patients.²⁰ However, studies of nutritional supplementation in those with CFS have shown no benefit.²¹

Treatment

Family physicians should focus initially on management of symptoms that are often comorbid with CFS, including sleep disturbances, depression, and pain. Any comorbidity identified should be treated.^7,8 Patients should be encouraged to take rest periods as necessary, and to practice relaxation techniques. Although there is no evidence these modalities are effective, they are unlikely to be harmful and may be helpful.⁸ There is substantial evidence for two treatments for CFS: cognitive behavior therapy (CBT) and graded exercise therapy. There is less clear evidence regarding the benefit of drug therapy for CFS in patients without comorbid depression or anxiety disorders.

COGNITIVE BEHAVIOR THERAPY

Trained psychotherapists providing CBT emphasize the role of thinking and its impact on how persons feel and act. They can help persons with CFS recognize how their fears of activity lead to behaviors that ultimately cause them to feel more fatigued and disabled. A large randomized controlled trial in adults with CFS confirmed that CBT has positive effects on fatigue levels, work and social adjustment, depression, anxiety, and postexertional malaise. Most patients in this study rated themselves as “much” or “very much” better after completion.²²

A 2008 Cochrane review also supported the use of CBT for CFS.²³ Several other studies have shown similar results,^24,25 including in adolescents with CFS.²⁶ One study found fewer school absences and improvements in fatigue and overall physical functioning in adolescents being treated with Internet-based CBT.²⁷ CBT has been studied in group settings²⁸ and in the form of self-guided instruction,²⁹ with questionable effectiveness. Because of this, it is recommended that CBT be individualized to maximize benefit.⁸ Disadvantages of CBT include the need for expert consultation, time considerations, and cost. There are no data to suggest that CBT provided by trained family physicians is better or worse than CBT provided by psychotherapists.

EXERCISE

Graded exercise therapy involves a gradual increase in physical activity in the hopes of increasing function. A randomized trial found that graded exercise therapy was as effective as CBT for fatigue and the other aspects of functional impairment mentioned previously, except depression.²² Participants in this trial were encouraged to gradually increase the duration of their physical activity over 52 weeks to a final goal of 30 minutes of light exercise five days per week, taking caution not to exceed a target heart rate to avoid overexertion. Most patients chose to walk for exercise. Once this goal was achieved, the patients worked with the supervising physiotherapists monthly to increase the intensity of their aerobic exercise.

Several other studies have found consistent results.^30–32 There is some evidence that the benefits of graded exercise therapy do not correlate with increases in exercise capacity, suggesting that the benefits of graded exercise therapy, like CBT, have more to do with decreasing symptom-focusing behavior in persons with CFS.³³ Impediments to graded exercise therapy include time considerations and concerns from patients that exercise will exacerbate their condition.

OTHER NONPHARMACOLOGIC TREATMENTS

One study has shown that an educational intervention known as pragmatic rehabilitation provided by specially trained nurses improves fatigue in persons with CFS; however, the improvement did not persist after 70 weeks. The intervention included education about CFS, followed by a negotiated treatment plan of gradually increased activity.³⁴ Although pragmatic rehabilitation is appealing because it avoids the need for expert consultation, more evidence is needed to determine if its effectiveness can be sustained.

Despite the positive results with CBT and graded exercise therapy, the effects are usually moderate and rarely lead to resolution of CFS. Patients with poor social adjustment, a strong belief in an organic cause for fatigue, or some sort of sickness benefit (i.e., financial incentive) tend to have worse responses to therapy.^15,35 Unlike with many other illnesses, membership in a CFS support group was associated with worse outcomes.³⁵

Other treatments that did not improve CFS symptoms in clinical trials include homeopathic treatments³⁶ and multivitamins.²¹

PHARMACOLOGIC THERAPY

Several pharmacologic treatments for CFS have had disappointing results in clinical trials, with weak effects of questionable clinical significance or no evidence of benefit at all. There is no good evidence to support the use of antiviral medications, hydrocortisone, or fludrocortisone; only small or poorly designed studies exist.^17,37,38

One study showed some clinical improvement in CFS after treatment with staphylococcus toxoid; the authors theorized that the treatment stimulated the hypoactive immune systems of persons with CFS and subsequently improved their fatigue. However, the treatment needed to be continued to prevent relapse of symptoms. Staphylococcus toxoid is not widely available and cannot currently be recommended as a treatment for CFS.³⁹

Other treatments that did not improve CFS symptoms in clinical trials include methylphenidate,⁴⁰ melatonin,¹⁹ citalopram (Celexa; used in patients without depression),⁴¹ and galantamine (Razadyne).⁴² More research is needed to clarify the etiology of CFS to better target potential treatments.

Data Sources: A PubMed search was completed using the MeSH term chronic fatigue syndrome. The search included randomized controlled trials and clinical trials in English from the past 10 years. We also searched the Cochrane database, Essential Evidence Plus, the National Institute for Health and Clinical Excellence guidelines, and the Centers for Disease Control and Prevention Web site. Search date: August 26, 2011.

Chronic Fatigue Syndrome (CFS) – Exams, Tests, Diagnosis, Related Conditions

Written by WebMD Editorial Contributors

• See Your Doctor
• What Else Could It Be?
• Checking the Symptoms

There’s no simple blood test or X-ray to diagnose chronic fatigue syndrome – also known as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). And many of the symptoms of the illness — deep tiredness, unrelieved by rest or sleep, feeling worse after physical or mental exertion, trouble concentrating, feeling worse after standing and remaining on one’s feet and other symptoms– are also seen in other conditions, too, making the diagnosis of ME/CFS more difficult.

If you think you might have ME/CFS, make an appointment to see your doctor. Research shows that getting treatment sooner might bring better results.

Your doctor will ask for a lot of information about your health. Unfortunately, there is not yet a diagnostic test that is sufficiently accurate to be useful. Your doctor will need to rule out other conditions or causes before they can diagnose ME/CFS.

They might order other tests like blood and urine tests and scans. They will need the names of all the prescription and over-the-counter medicine you take, in case one of them is causing your symptoms. Also, tell your doctor if you take any supplements. Even so-called “natural” or “herbal” remedies can have side effects, and they might cause problems if used with other medications you’re taking.

Your doctor will give you a complete physical exam and ask you questions about your emotions. This will give them a better idea of what your needs are. It’s important to make sure you don’t have another disorder, which could be serious and could get better with treatment.

Many people who have ME/CFS have other conditions, too. If you get treated for those, it might also improve your chronic fatigue.

 ME/CFS can look a lot like “mono” (mononucleosis), Lyme disease, lupus, multiple sclerosis, fibromyalgia, sleep disorders, or depression. It affects about 2.5 million Americans, but experts believe only about 20% are diagnosed. 

Your doctor will review your medical history and test results. They will check to see if you have several key symptoms, beginning with extreme tiredness, or fatigue, that doesn’t improve with bed rest for 6 months or longer.

Then, your doctor will check to see if you have three of these “core” symptoms of CFS:

• Reduced ability to do usual activities for six months or more because of fatigue
• Worsening of symptoms (difficulty thinking, problems sleeping, sore throat, headaches, feeling dizzy, or severe tiredness).  after physical or mental exertion
• Trouble falling asleep or staying asleep, and awakening unrested

Along with the three symptoms, you must have one of these for a diagnosis of ME/CFS:

• Problems with thinking and memory
• Worsening of symptoms while standing or sitting upright; you might feel lightheaded, dizzy or weak, and you may have blurred vision or see spots.

It could take a while to get your diagnosis. It’s OK to ask how you can relieve your symptoms while you wait. Your doctor or health professional will schedule follow-up appointments to see how your treatment is working.

Top Picks

5.

1. Diagnosis and treatment of varicothrombophlebitisPhlebological Center “Antireflux”

• ← Chapter 4 THROMBOPHILIA. ETIOLOGY AND PATHOGENESIS. MARKERS FOR THROMBOPHILIC CONDITIONS
• Contents
• → 5.2. Clinical picture and diagnosis of deep vein thrombosis

The term “thrombophlebitis” refers to thrombotic lesions of the saphenous veins with clinical signs of inflammation. Most often, thrombophlebitis is a complication of varicose transformation of the saphenous veins – varicothrombophlebitis.

Diagnosis

Clinical manifestations of varicothrombophlebitis are pain, hyperemia in the projection of the affected vein, local fever, hyperesthesia of the skin, and the presence of a cord-like, dense cord on palpation (Fig. 5.1). Patients with suspected varicothrombophlebitis should purposefully find out the presence of symptoms indicating deep vein thrombosis and pulmonary embolism.

The main method for diagnosing varicothrombophlebitis is duplex scanning of veins with compression tests. Ultrasound examination allows to determine the localization of thrombotic masses, the nature of the thrombus (occlusive, parietal, floating), its distal and proximal boundaries (Fig. 5.2). Ultrasonic angioscanning also makes it possible to assess the patency of deep and perforating veins, and provides indicative information about the duration of the process. The ultrasound protocol must necessarily include an examination of the saphenous and deep veins of not only the affected, but also the contralateral limb.

Fig. 5.1. Thrombophlebitis of the tributaries of the great saphenous vein on the leg

5.2. Thrombosis of the GSV with thrombus spread through the SPS

Treatment

Treatment depends on the cause and localization of thrombophlebitis. The main goals of the treatment of varicothrombophlebitis are to reduce the effects of acute inflammation and prevent potentially dangerous complications, such as deep vein thrombosis and PE. Conservative treatment of varicothrombophlebitis includes an active regimen, elastic compression of the lower extremities, local and systemic pharmacotherapy. Anticoagulants in therapeutic doses are indicated for patients who have had a thrombus transfer to the deep venous system. With severe pain, it is advisable to use non-steroidal anti-inflammatory drugs (NSAIDs) orally for 5-7 days. Local treatment includes cold, preparations containing heparin, compresses with NSAIDs. Indications for surgical treatment are the localization of thrombophlebitis in the proximal saphenous veins, the spread of thrombosis from the distal to the proximal segment, despite ongoing therapy (ascending thrombophlebitis), the spread of thrombosis through fistulas or perforating veins to the deep venous system. The main type of surgical treatment is crossectomy and, if necessary, thrombectomy from the main veins. Some authors with the development of thrombosis of the saphenous veins against the background of varicose disease recommend the simultaneous implementation of radical phlebectomy.

Table 5.1. Therapeutic tactics for thrombosis of the saphenous veins of the lower extremities (according to the Russian clinical guidelines for the diagnosis, treatment and prevention of venous thromboembolic complications, approved by the council of experts in 2009)

• ← Chapter 4 THROMBOPHILIA. ETIOLOGY AND PATHOGENESIS. MARKERS FOR THROMBOPHILIC CONDITIONS
• Contents
• → 5.2. Clinical picture and diagnosis of deep vein thrombosis

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Using System File Checker to Repair Missing or Corrupted System Files

If some Windows features don’t work or Windows shuts down, use System File Checker to scan Windows and repair files.

Although the steps below may seem complicated at first, just follow them in order and we will try to help you.

Run System File Checker (SFC.exe)

by doing the following.

1. Open an elevated command prompt. To do this, follow the steps below, depending on the operating system version:

2. Windows 10, Windows 8.1, or Windows 8 users must run Deployment Image Servicing and Management (DISM) before running System File Checker. (If your computer is running Windows 7 or Windows Vista, skip to step 3.)

Type the following command, and then press ENTER. The command may take several minutes to complete.

DISM.exe /Online /Cleanup-image /Restorehealth

Important! When you run this command, DISM contacts Windows Update to obtain files to repair corruption. However, if the Windows Update client is corrupted, use a running instance of Windows as a recovery source, or a parallel Windows folder from a network location or removable media such as a Windows DVD as a source of files. To do this, enter the following command at the command line:

DISM.exe /Online /Cleanup-Image /RestoreHealth /Source: C:\RepairSource\Windows /LimitAccess

Note. Replace the placeholder C:\RepairSource\Windows with the location of your repair source. For more information about using the DISM tool to repair Windows, see Repair a Windows Image.

1. Type the following command at the command prompt, and then press ENTER:

sfc /scannow

The sfc /scannow command will scan all protected system files and replace corrupted files with their cached copy located in a compressed folder at %WinDir% \System32\dllcache.
The %WinDir% placeholder is a Windows operating system folder. For example, C:\Windows.

Note. Do not close this command line window until the verification is 100% complete. The results of the verification will be shown after the completion of this process.

1. After the verification process is completed, one of the following messages may appear on the screen:

   • Windows Resource Protection found no integrity violations.

     
     This means that missing and corrupted system files are not found.

   • Windows Resource Protection could not perform the requested operation.

     
     To resolve this issue, scan with the System File Checker in Safe Mode, verify that the PendingDeletes and PendingRenames folders are in folder %WinDir% \WinSxS\Temp.

   • Windows Resource Protection found corrupted files and successfully repaired them. See CBS.Log %WinDir% \Logs\CBS\CBS.log for details.

     
     To view detailed information about scanning and restoring system files, go to How to view detailed information about the System File Checker process.

   • Windows Resource Protection found corrupted files but was unable to repair some of them. See CBS.Log %WinDir% \Logs\CBS\CBS. log for details.

     
     To manually repair corrupted files, review the details of the System File Checker process to find the corrupted file, and then manually replace the corrupted file with a guaranteed working copy.

Swipe in from the right edge of the screen to the center and tap Search . Or, if you are using a mouse, move the pointer to the lower right corner of the screen and click the Search button. Type Command Prompt in the Search field, right-click Command Prompt , then select Run as administrator . If the system asks for an administrator password or confirmation, enter the password or click the Allow button.

To do this, click the Start button , type Command Prompt or cmd in the Search field, right-click Command Prompt , and then select Run as Administrator . If you are prompted for an administrator password or confirmation, enter the password or press the Allow .

Additional information

View detailed information about the operation of the System File Checker.

To see the details included in the CBS.Log file, you can copy the details to the Sfcdetails.txt file using the Findstr command and then view them in that file. To do this, follow the steps below.

1. Open an elevated command prompt as described in step 1.

2. At the command prompt, type the following command, and then press ENTER:

   findstr /c:"[SR]" %windir%\Logs\CBS\CBS. log >"%userprofile%\Desktop\sfcdetails.txt" 

   Note. The Sfcdetails.txt file contains information about each run of System File Checker on the computer. It also contains information about files that were not fixed by the System File Checker. Check the date and time of the entries to determine the problematic files found the last time you ran System File Checker.

3. Open the Sfcdetails.txt file on your desktop.

4. The Sfcdetails.txt file uses the following format:

   SFC date and time information
   The following log file example contains an entry for one file that could not be repaired:

   2007-01-12 12:10:42, Info CSI 00000008 [SR] Cannot
   repair member file [l:34{17}]”Accessibility. dll” of Accessibility, Version =
   6.0.6000.16386, pA = PROCESSOR_ARCHITECTURE_MSIL(8), Culture neutral,
   VersionScope neutral, PublicKeyToken = {l:8 b:b03f5f7f11d50a3a}, Type
   neutral, TypeName neutral, PublicKey neutral in the store, file is missing

How to manually replace a damaged system file with a guaranteed working copy of the file.

After determining which system file is corrupted and cannot be repaired using the details in the Sfcdetails.txt file, locate the corrupted file, then manually replace the corrupted file with a guaranteed working copy. To do this, follow the steps below.

Note. A guaranteed working copy of the system file can be taken from another computer that has the same version of Windows installed as your computer. To make sure that a system file that you plan to copy to another computer is working, you can run the verification process with the System File Checker.

1. Proprietorize the corrupted system file to administrator ownership. To do this, copy and then paste (or type) the following command into an elevated command prompt, then press ENTER:

   takeown /f Path_and_file_name
   Note. Placeholder Path_and_file_name is the path and filename for the corrupted file. For example, type takeown /f C:\windows\system32\jscript.dll.

2. Give administrators full access to a corrupted system file. To do this, copy and paste (or type) the following command and press Enter:

   icacls Path_and_file_name /GRANT ADMINISTRATORS:F
   Note. Placeholder Path_and_file_name is the path and filename for the corrupted file.