{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,20]],"date-time":"2025-10-20T18:51:30Z","timestamp":1760986290018,"version":"build-2065373602"},"reference-count":46,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2024,8,22]],"date-time":"2024-08-22T00:00:00Z","timestamp":1724284800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"BC SUPPORT Unit","award":["FHA G2020-005","FHA G2020-014","FHA G2017-001"],"award-info":[{"award-number":["FHA G2020-005","FHA G2020-014","FHA G2017-001"]}]},{"name":"Surrey Hospitals Foundation","award":["FHA G2020-005","FHA G2020-014","FHA G2017-001"],"award-info":[{"award-number":["FHA G2020-005","FHA G2020-014","FHA G2017-001"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background\/Objectives: Myalgic encephalomyelitis\/chronic fatigue syndrome (ME\/CFS) is a neurological disorder characterized by post-exertional malaise. Despite its clinical relevance, the disease mechanisms of ME\/CFS are not fully understood. The previous studies targeting brain function or metabolites have been inconclusive in understanding ME\/CFS complexity. We combined single-voxel magnetic resonance spectroscopy (SV-MRS) and functional magnetic resonance imaging (fMRI). Our objectives were to examine the feasibility of the multimodal MRI protocol, identify possible differences between ME\/CFS and healthy controls (HCs), and relate MRI findings with clinical symptoms. Methods: We enrolled 18 female ME\/CFS participants (mean age: 39.7 \u00b1 12.0 years) and five HCs (mean age: 45.6 \u00b1 14.5 years). SV-MRS spectra were acquired from three voxels of interest: the anterior cingulate gyrus (ACC), brainstem (BS), and left dorsolateral prefrontal cortex (L-DLPFC). Whole-brain fMRI used n-back task testing working memory and executive function. The feasibility was assessed as protocol completion rate and time. Group differences in brain metabolites and fMRI activation between ME\/CFS and HCs were compared and correlated with behavioral and symptom severity measurements. Results: The completion rate was 100% regardless of participant group without causing immediate fatigue. ME\/CFS appeared to show a higher N-Acetylaspartate in L-DLPFC compared to HCs (OR = 8.49, p = 0.040), correlating with poorer fatigue, pain, and sleep quality scores (p\u2019s = 0.001\u20130.015). An increase in brain activation involving the frontal lobe and the brainstem was observed in ME\/CFS compared to HCs (Z &gt; 3.4, p\u2019s &lt; 0.010). Conclusions: The study demonstrates the feasibility of combining MRS and fMRI to capture neurochemical and neurophysiological features of ME\/CFS in female participants. Further research with larger cohorts of more representative sampling and follow-ups is needed to validate these apparent differences between ME\/CFS and HCs.<\/jats:p>","DOI":"10.3390\/medicina60081370","type":"journal-article","created":{"date-parts":[[2024,8,22]],"date-time":"2024-08-22T06:28:51Z","timestamp":1724308131000},"page":"1370","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["A Multimodal Magnetic Resonance Imaging Study on Myalgic Encephalomyelitis\/Chronic Fatigue Syndrome: Feasibility and Clinical Correlation"],"prefix":"10.3390","volume":"60","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-2746-2263","authenticated-orcid":false,"given":"Raminder","family":"Kaur","sequence":"first","affiliation":[{"name":"Research and Evaluation, Fraser Health Authority, Surrey, BC V3T 0H1, Canada"},{"name":"Biomedical Physiology & Kinesiology, Simon Fraser University, Burnaby, BC V5A 1S6, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5117-3866","authenticated-orcid":false,"given":"Brian","family":"Greeley","sequence":"additional","affiliation":[{"name":"Research and Evaluation, Fraser Health Authority, Surrey, BC V3T 0H1, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander","family":"Ciok","sequence":"additional","affiliation":[{"name":"Research and Evaluation, Fraser Health Authority, Surrey, BC V3T 0H1, Canada"},{"name":"Biomedical Physiology & Kinesiology, Simon Fraser University, Burnaby, BC V5A 1S6, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-4865-2090","authenticated-orcid":false,"given":"Kashish","family":"Mehta","sequence":"additional","affiliation":[{"name":"Research and Evaluation, Fraser Health Authority, Surrey, BC V3T 0H1, Canada"},{"name":"Biomedical Physiology & Kinesiology, Simon Fraser University, Burnaby, BC V5A 1S6, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Melody","family":"Tsai","sequence":"additional","affiliation":[{"name":"Women\u2019s Health Research Institute, Vancouver, BC V6H 3N1, Canada"},{"name":"Complex Chronic Diseases Program, BC Women\u2019s Hospital, Vancouver, BC V6H 3N1, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hilary","family":"Robertson","sequence":"additional","affiliation":[{"name":"ME\/FM Society of BC, Vancouver, BC V6J 5M4, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kati","family":"Debelic","sequence":"additional","affiliation":[{"name":"ME\/FM Society of BC, Vancouver, BC V6J 5M4, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5918-8082","authenticated-orcid":false,"given":"Lan Xin","family":"Zhang","sequence":"additional","affiliation":[{"name":"Research and Evaluation, Fraser Health Authority, Surrey, BC V3T 0H1, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Todd","family":"Nelson","sequence":"additional","affiliation":[{"name":"Research and Evaluation, Fraser Health Authority, Surrey, BC V3T 0H1, Canada"},{"name":"Biomedical Physiology & Kinesiology, Simon Fraser University, Burnaby, BC V5A 1S6, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Travis","family":"Boulter","sequence":"additional","affiliation":[{"name":"Complex Chronic Diseases Program, BC Women\u2019s Hospital, Vancouver, BC V6H 3N1, Canada"},{"name":"ME\/FM Society of BC, Vancouver, BC V6J 5M4, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"William","family":"Siu","sequence":"additional","affiliation":[{"name":"Medical Imaging, Royal Columbian Hospital, New Westminster, BC V3L 3W7, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Luis","family":"Nacul","sequence":"additional","affiliation":[{"name":"Women\u2019s Health Research Institute, Vancouver, BC V6H 3N1, Canada"},{"name":"Complex Chronic Diseases Program, BC Women\u2019s Hospital, Vancouver, BC V6H 3N1, Canada"},{"name":"Department of Family Practice, University of British Columbia, Vancouver, BC V6T 1Z3, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9589-2520","authenticated-orcid":false,"given":"Xiaowei","family":"Song","sequence":"additional","affiliation":[{"name":"Research and Evaluation, Fraser Health Authority, Surrey, BC V3T 0H1, Canada"},{"name":"Biomedical Physiology & Kinesiology, Simon Fraser University, Burnaby, BC V5A 1S6, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2024,8,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1515\/reveh-2015-0026","article-title":"Review of Myalgic Encephalomyelitis\/Chronic Fatigue Syndrome: An evidence-based approach to diagnosis and management by clinicians","volume":"30","author":"Bested","year":"2015","journal-title":"Rev. Environ. Health"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Cortes Rivera, M., Mastronardi, C., Silva-Aldana, C.T., Arcos-Burgos, M., and Lidbury, B.A. (2019). Myalgic Encephalomyelitis\/Chronic Fatigue Syndrome: A Comprehensive Review. Diagnostics, 9.","DOI":"10.3390\/diagnostics9030091"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"471","DOI":"10.1186\/s12967-021-03143-3","article-title":"An attempt to explain the neurological symptoms of Myalgic Encephalomyelitis\/Chronic Fatigue Syndrome","volume":"19","author":"Wirth","year":"2021","journal-title":"J. Transl. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"100","DOI":"10.1186\/s12967-020-02269-0","article-title":"Systematic review and meta-analysis of the prevalence of chronic fatigue syndrome\/myalgic encephalomyelitis (CFS\/ME)","volume":"18","author":"Lim","year":"2020","journal-title":"J. Transl. Med."},{"key":"ref_5","unstructured":"Canadian Institutes of Health Research (2024, August 08). A Conversation about Myalgic Encephalomyelitis with Dr. Nina Muirhead [Internet]., Available online: https:\/\/cihr-irsc.gc.ca\/e\/52474.html."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Chuluunbaatar-Lussier, E., Tsai, M., Boulter, T., Mu\u00f1oz, C., Kerr, K., and Nacul, L. (2024, August 08). Epidemiology of Myalgic Encephalomyelitis among Individuals with Self-Reported Chronic Fatigue Syndrome in British Columbia, Canada, and Their Health-Related Quality of Life. 24307437. Available online: https:\/\/www.medrxiv.org\/content\/10.1101\/2024.05.16.24307437v1.","DOI":"10.1101\/2024.05.16.24307437"},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Brittain, E., Muirhead, N., Finlay, A., and Vyas, J. (2021). Myalgic Encephalomyelitis\/Chronic Fatigue Syndrome (ME\/CFS): Major Impact on Lives of Both Patients and Family Members. Med. J., 57.","DOI":"10.3390\/medicina57010043"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Nacul, L., O\u2019Boyle, S., Palla, L., Nacul, F.E., Mudie, K., Kingdon, C.C., Cliff, J.M., Clark, T.G., Dockrell, H.M., and Lacerda, E.M. (2020). How Myalgic Encephalomyelitis\/Chronic Fatigue Syndrome (ME\/CFS) Progresses: The Natural History of ME\/CFS. Front. Neurol., 11.","DOI":"10.3389\/fneur.2020.00826"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Gandasegui, I.M., Laka, L.A., Gargiulo, P.\u00c1., G\u00f3mez-Esteban, J.C., and S\u00e1nchez, J.V.L. (2021). Myalgic Encephalomyelitis\/Chronic Fatigue Syndrome: A Neurological Entity?. Medicina, 57.","DOI":"10.3390\/medicina57101030"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Murga, I., Aranburu, L., Gargiulo, P.A., G\u00f3mez Esteban, J.C., and Lafuente, J.V. (2021). Clinical Heterogeneity in ME\/CFS. A Way to Understand Long-COVID19 Fatigue. Front. Psychiatry, 12.","DOI":"10.3389\/fpsyt.2021.735784"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1186\/s12967-020-02506-6","article-title":"Neuroimaging characteristics of myalgic enceph-alomyelitis\/chronic fatigue syndrome (ME\/CFS): A systematic review","volume":"18","author":"Shan","year":"2020","journal-title":"J. Transl. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"e031672","DOI":"10.1136\/bmjopen-2019-031672","article-title":"Using structural and functional MRI as a neuroimaging technique to investigate chronic fatigue syndrome\/myalgic encephalopathy: A systematic review","volume":"10","author":"Almutairi","year":"2020","journal-title":"BMJ Open"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Maksoud, R., Preez S du Eaton-Fitch, N., Thapaliya, K., Barnden, L., Cabanas, H., Staines, D., and Marshall-Gradisnik, S. (2020). A systematic review of neurological im-pairments in myalgic encephalomyelitis\/chronic fatigue syndrome using neuroimaging techniques. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0232475"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"562","DOI":"10.1007\/s11682-018-0029-4","article-title":"Evidence of widespread metabolite abnormalities in Myalgic En-cephalomyelitis\/Chronic Fatigue Syndrome: Assessment with whole-brain Magnetic Resonance Spectroscopy","volume":"14","author":"Mueller","year":"2019","journal-title":"Brain Imaging Behav."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1007\/s00213-021-05986-6","article-title":"Neurochemical abnormalities in chronic fatigue syndrome: A pilot magnetic resonance spectroscopy study at 7 Tesla","volume":"239","author":"Godlewska","year":"2022","journal-title":"Psychopharmacology"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"609","DOI":"10.1515\/revneuro-2015-0010","article-title":"Magnetic resonance spectroscopy of the brain: A review of physical principles and technical methods","volume":"26","author":"Buonocore","year":"2015","journal-title":"Rev. Neurosci."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"527","DOI":"10.1002\/mrm.27742","article-title":"Methodological consensus on clinical proton MRS of the brain: Review and recommendations","volume":"82","author":"Wilson","year":"2019","journal-title":"Magn. Reson. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"907","DOI":"10.1038\/s41467-024-45107-3","article-title":"Deep phenotyping of post-infectious myalgic enceph-alomyelitis\/chronic fatigue syndrome","volume":"15","author":"Walitt","year":"2024","journal-title":"Nat. Commun."},{"key":"ref_19","first-page":"6","article-title":"Functional magnetic resonance imaging","volume":"75","author":"Matthews","year":"2004","journal-title":"J. Neurol. Neurosurg. Psychiatry."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"954","DOI":"10.1037\/neu0000426","article-title":"Functional Brain Imaging in Neuropsychology over the past 25 years","volume":"31","author":"Roalf","year":"2017","journal-title":"Neuropsychology"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"358","DOI":"10.1016\/j.biopsych.2016.07.016","article-title":"Prefrontal Structure Varies as a Function of Pain Symptoms in Chronic Fatigue Syndrome","volume":"81","author":"Schaaf","year":"2017","journal-title":"Biol. Psychiatry"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Nelson, T., Zhang, L.X., Guo, H., Nacul, L., and Song, X. (2021). Brainstem Abnormalities in Myalgic Encephalomyelitis\/Chronic Fatigue Syn-drome: A Scoping Review and Evaluation of Magnetic Resonance Imaging Findings. Front. Neurol., 12.","DOI":"10.3389\/fneur.2021.769511"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"947","DOI":"10.1097\/01.psy.0000242770.50979.5f","article-title":"Probing the working memory system in chronic fatigue syndrome: A functional magnetic resonance imaging study using the n-back task","volume":"68","author":"Caseras","year":"2006","journal-title":"Psychosom. Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"117326","DOI":"10.1016\/j.jns.2021.117326","article-title":"Modulatory effects of cognitive exertion on regional functional connectivity of the salience network in women with ME\/CFS: A pilot study","volume":"422","author":"Manca","year":"2021","journal-title":"J. Neurol. Sci."},{"key":"ref_25","unstructured":"Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis\/ChronicFatigue Syndrome, Board on the Health of Select Populations, Institute of Medicine (2024, August 08). Beyond Myalgic Encephalomyelitis\/Chronic Fatigue Syndrome: Redefining an Illness, Available online: http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK274235\/."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1136\/jcp.2006.042754","article-title":"Definitions and aetiology of myalgic encephalomyelitis: How the Canadian consensus clinical definition of myalgic encephalomyelitis works","volume":"60","author":"Carruthers","year":"2007","journal-title":"J. Clin. Pathol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1002\/mrm.26091","article-title":"Advanced processing and simulation of MRS data using the FID appliance (FID-A)-An open source, MATLAB-based toolkit","volume":"77","author":"Simpson","year":"2017","journal-title":"Magn. Reson. Med."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Near, J., Harris, A.D., Juchem, C., Kreis, R., Marja\u0144ska, M., \u00d6z, G., Slotboom, J., Wilson, M., and Gasparovic, C. (2021). Preprocessing, analysis and quantification in single-voxel magnetic resonance spectroscopy: Experts\u2019 consensus recommendations. NMR Biomed., 34.","DOI":"10.1002\/nbm.4257"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"672","DOI":"10.1002\/mrm.1910300604","article-title":"Estimation of metabolite concentrations from localized in vivo proton NMR spectra","volume":"30","author":"Provencher","year":"1993","journal-title":"Magn. Reson. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"2950","DOI":"10.1002\/mrm.28630","article-title":"FSL-MRS: An end-to-end spectroscopy analysis package","volume":"85","author":"Clarke","year":"2021","journal-title":"Magn. Reson. Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"232","DOI":"10.1016\/j.neuroimage.2014.03.034","article-title":"ICA-based artefact removal and accelerated fMRI acquisition for improved resting state network imaging","volume":"95","author":"Griffanti","year":"2014","journal-title":"NeuroImage"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/j.jcm.2016.02.012","article-title":"A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research","volume":"15","author":"Koo","year":"2016","journal-title":"J. Chiropr. Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1748","DOI":"10.1016\/j.neuroimage.2003.12.024","article-title":"Constrained linear basis sets for HRF modelling using Variational Bayes","volume":"21","author":"Woolrich","year":"2004","journal-title":"NeuroImage"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1732","DOI":"10.1016\/j.neuroimage.2003.12.023","article-title":"Multilevel linear modelling for FMRI group analysis using Bayesian inference","volume":"21","author":"Woolrich","year":"2004","journal-title":"NeuroImage"},{"key":"ref_35","unstructured":"Harvard Oxford Atlas (2024, August 08). Nilearn. Available online: https:\/\/nilearn.github.io\/dev\/modules\/description\/harvard_oxford.html."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Nacul, L.C., Mudie, K., Kingdon, C.C., Clark, T.G., and Lacerda, E.M. (2018). Hand Grip Strength as a Clinical Biomarker for ME\/CFS and Disease Severity. Front. Neurol., 9.","DOI":"10.3389\/fneur.2018.00992"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"e085272","DOI":"10.1136\/bmjopen-2024-085272","article-title":"Low-dose naltrexone for post-COVID fatigue syndrome: A study protocol for a double-blind, randomised trial in British Columbia","volume":"14","author":"Naik","year":"2024","journal-title":"BMJ Open"},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Rebelos, E., Daniele, G., Campi, B., Saba, A., Koskensalo, K., Ihalainen, J., Saukko, E., Nuutila, P., Backes, W.H., and Jansen, J.F.A. (2022). Circulating N-Acetylaspartate does not track brain NAA concentrations, cognitive function or features of small vessel disease in humans. Sci. Rep., 12.","DOI":"10.1038\/s41598-022-15670-0"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"168","DOI":"10.2174\/1570159X11666131120224653","article-title":"Oxidative and Nitrosative Stress and Immune-Inflammatory Pathways in Patients with Myalgic En-cephalomyelitis (ME)\/Chronic Fatigue Syndrome (CFS)","volume":"12","author":"Morris","year":"2014","journal-title":"Curr. Neuropharmacol."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Vanelzakker, M., Brumfield, S., and Mejia, P. (2019). Neuroinflammation and Cytokines in Myalgic Encephalomyelitis\/Chronic Fatigue Syndrome (ME\/CFS): A Critical Review of Research Methods. Front. Neurol., 10.","DOI":"10.3389\/fneur.2019.00316"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1206","DOI":"10.1259\/bjr.73.875.11144799","article-title":"Proton magnetic resonance spectroscopy and morphometry of the hippo-campus in chronic fatigue syndrome","volume":"73","author":"Brooks","year":"2000","journal-title":"Br. J. Radiol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"102366","DOI":"10.1016\/j.nicl.2020.102366","article-title":"Mapping of pathological change in chronic fatigue syndrome using the ratio of T1- and T2-weighted MRI scans","volume":"28","author":"Thapaliya","year":"2020","journal-title":"NeuroImage Clin."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1305","DOI":"10.1016\/j.jalz.2018.07.219","article-title":"Whitepaper: Defining and investi-gating cognitive reserve, brain reserve, and brain maintenance","volume":"16","author":"Stern","year":"2020","journal-title":"Alzheimers Dement."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"103484","DOI":"10.1016\/j.autrev.2023.103484","article-title":"Brain-regional characteristics and neuroinflammation in ME\/CFS patients from neuroimaging: A systematic review and meta-analysis","volume":"23","author":"Lee","year":"2024","journal-title":"Autoimmun. Rev."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1080\/21641846.2023.2245584","article-title":"Home-based testing protocol to measure physiological responses to everyday activities in ME: A feasibility study","volume":"11","author":"Tyson","year":"2023","journal-title":"Fatigue Biomed. Health Behav."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1111\/j.1365-2796.2011.02428.x","article-title":"Myalgic encephalomyelitis: International Consensus Criteria","volume":"270","author":"Carruthers","year":"2011","journal-title":"J. Intern. Med."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/60\/8\/1370\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T15:41:01Z","timestamp":1760110861000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/60\/8\/1370"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,8,22]]},"references-count":46,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2024,8]]}},"alternative-id":["medicina60081370"],"URL":"https:\/\/doi.org\/10.3390\/medicina60081370","relation":{},"ISSN":["1648-9144"],"issn-type":[{"type":"electronic","value":"1648-9144"}],"subject":[],"published":{"date-parts":[[2024,8,22]]}}}