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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Primary &#40;or pure&#41; chronic fatigue syndrome &#40;pCFS&#41; is a complex and severe chronic and disabling disease of unknown causes&#44; excluding secondary chronic fatigue syndrome &#40;sCFS&#41; related to some other medical condition&#46; It is characterized by intense fatigue in addition to cognitive&#44; autonomic&#44; neuroendocrine&#44; immunoallergic and musculoskeletal symptoms&#44; which are of recent appearance and that cannot be explained by other clinical reasons&#44; lasting for at least 6 months&#44; is non-remitting significantly with rest and which worsens with physical or mental activity&#44; with very slow recovery and a reduction of &#62;50&#37; of activities of daily living previously performed by the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> It is diagnosed according to the 1994 Fukuda criteria&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the Canadian consensus document published in 2003<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> or&#44; more recently&#44; the international consensus criteria of 2011&#59; with the name of myalgic encephalomyelitis that offers a review on its physiopathology&#44; symptoms and treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Prevalence is estimated to be between 0&#46;5&#37; and 2&#46;5&#37; of the general population&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3&#44;5</span></a> In spite of it being recognized as a disease by the WHO since 1989&#44; and classified with the code G93&#46;3 in the ICD-10&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> and that evidence accumulated from different fields during the past 2 decades&#44; it is possible that pCFS is still largely unknown by most health professionals&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Due to the great heterogeneity in its clinical expression and the lack of standardized instruments to order its different symptoms &#40;according to greater or lesser frequency&#41; and clinical presentation &#40;distinguishing between pCFS&#44; sCFS and Idiopathic CF&#41;&#44; we propose a classification into clusters&#58; I&#44; II&#44; IIIa&#44; IIIb and IIIc&#44; subgrouping the main clinical conditions in a consecutive series of 199 patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; seen in a period of time between June 2010 and February 2013 at the Chronic Fatigue Specialized Hospital Unit of the Camp de Tarragona belonging to the Hospital Universitario Joan <span class="elsevierStyleSmallCaps">XXIII</span>&#46; 84&#37; of patients &#40;n&#61;167&#41; were women &#40;5&#58;1&#41;&#46; Mean age at symptom onset was 41&#46;5 years &#40;range 9&#8211;76&#41;&#46; The onset of symptoms was insidious in 72&#46;8&#37; of patients and 71&#46;3&#37; had a progressive evolution of disease&#46; At the moment of interview&#44; 51&#46;7&#37; &#40;n&#61;103&#41; were unemployed &#40;65 lost their job while 38 were disabled&#41;&#46; 8&#37; &#40;n&#61;16&#41; were retired&#46; The pCFS criteria are valid for the diagnosis in the clinical daily practice independently of other associated criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> Having a classification of patients with CFS will allow us to identify more homogeneous groups of patients&#44; candidates both for more individualized diagnostic and therapeutic guidelines and which allow for better expectations&#46; In order to correctly classify a patient with CFS&#44; we recommend a multidisciplinary approach&#46; In first place&#44; the CFS diagnosis must be confirmed &#40;family physician&#44; internal medicine specialist and&#47;or rheumatologist&#41;&#44; in order to then evaluate the existence of possible associated systemic diseases or chronic local processes that have a large differential diagnosis and&#44; finally&#44; to perform a precise diagnosis of the disease with a psychopathological background &#40;psychologist and&#47;or psychiatrist&#41;&#46; Having a clear diagnosis in each one of these 6 areas&#44; as well as the analysis of the chronology of symptoms or processes allows the inclusion of the patient into each one of the different classification subgroups&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Qanneta R&#44; Fontova R&#44; Poveda MJ&#44; Castro S&#46; Tipolog&#237;a cl&#237;nica del s&#237;ndrome de fatiga cr&#243;nica&#58; hip&#243;tesis clasificatoria&#46; Reumatol Clin&#46; 2014&#59;10&#58;132&#8211;133&#46;</p>"
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                  \t\t\t\t">None&#44; 36&#47;199 patients &#40;18&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#47;36 patients &#40;13&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cluster IIIa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">sCFS autoimmune disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">17&#47;199 patients &#40;8&#46;5&#37;&#41;&#8226; 9 patients with primary Sj&#246;gren&#39;s syndrome<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#8226; 4 patients with polymyalgia rheumatica&#8226; 2 patients with systemic lupus erythematosus&#8226; 1 patient with Crohn&#39;s disease&#8226; 1 patient with Guillain&#8211;Barr&#233;&#8217;s syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#47;17 patients &#40;41&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Cluster IIIb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">sCFS to other medical entities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">40&#47;199 patients &#40;20&#46;1&#37;&#41;&#8226; 7 postchemotherapy patients&#8226; 6 patients due to drugs&#8226; 5 patients with severe OSA&#8226; 3 patients with a secreting hypophiseal microadenoma&#8226; 3 patients with hepatic cirrhosis&#8226; 3 patients with morbid obesity&#8226; 3 patients with severe iron deficiency&#8226; 3 patients with meopause&#8226; 2 patients with COPD&#8226; 2 patients with type TE JAK2 V617F CMPS&#8226; 1 patient with multiple myeloma&#8226; 1 patient with neuromuscular lung disease&#8226; 1 patient with severe myocardiopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#47;40 patients &#40;15&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Cluster IIIc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">sCFS to psychopathologic abnormalities&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16&#47;199 patients &#40;8&#37;&#41;&#8226; 12 patients with depression&#8226; 3 patients with somatization&#8226; 1 patient with schizophrenia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#47;16 patients &#40;6&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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Letter to the Editor
Clinical Typology of Chronic Fatigue Syndrome: Classificatory Hypothesis
Tipología clínica del síndrome de fatiga crónica: hipótesis clasificatoria
Rami Qannetaa,
Corresponding author
rami_kanita229@hotmail.com

Corresponding author.
, Ramon Fontovab, María José Povedab, Sonia Castrob
a Unidad de Fatiga Crónica, Departamento de Reumatología, Hospital Universitari Joan XXIII, Tarragona, Spain
b Departamento de Reumatología, Hospital Universitari Joan XXIII, Tarragona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Primary &#40;or pure&#41; chronic fatigue syndrome &#40;pCFS&#41; is a complex and severe chronic and disabling disease of unknown causes&#44; excluding secondary chronic fatigue syndrome &#40;sCFS&#41; related to some other medical condition&#46; It is characterized by intense fatigue in addition to cognitive&#44; autonomic&#44; neuroendocrine&#44; immunoallergic and musculoskeletal symptoms&#44; which are of recent appearance and that cannot be explained by other clinical reasons&#44; lasting for at least 6 months&#44; is non-remitting significantly with rest and which worsens with physical or mental activity&#44; with very slow recovery and a reduction of &#62;50&#37; of activities of daily living previously performed by the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> It is diagnosed according to the 1994 Fukuda criteria&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the Canadian consensus document published in 2003<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> or&#44; more recently&#44; the international consensus criteria of 2011&#59; with the name of myalgic encephalomyelitis that offers a review on its physiopathology&#44; symptoms and treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Prevalence is estimated to be between 0&#46;5&#37; and 2&#46;5&#37; of the general population&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3&#44;5</span></a> In spite of it being recognized as a disease by the WHO since 1989&#44; and classified with the code G93&#46;3 in the ICD-10&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> and that evidence accumulated from different fields during the past 2 decades&#44; it is possible that pCFS is still largely unknown by most health professionals&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Due to the great heterogeneity in its clinical expression and the lack of standardized instruments to order its different symptoms &#40;according to greater or lesser frequency&#41; and clinical presentation &#40;distinguishing between pCFS&#44; sCFS and Idiopathic CF&#41;&#44; we propose a classification into clusters&#58; I&#44; II&#44; IIIa&#44; IIIb and IIIc&#44; subgrouping the main clinical conditions in a consecutive series of 199 patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; seen in a period of time between June 2010 and February 2013 at the Chronic Fatigue Specialized Hospital Unit of the Camp de Tarragona belonging to the Hospital Universitario Joan <span class="elsevierStyleSmallCaps">XXIII</span>&#46; 84&#37; of patients &#40;n&#61;167&#41; were women &#40;5&#58;1&#41;&#46; Mean age at symptom onset was 41&#46;5 years &#40;range 9&#8211;76&#41;&#46; The onset of symptoms was insidious in 72&#46;8&#37; of patients and 71&#46;3&#37; had a progressive evolution of disease&#46; At the moment of interview&#44; 51&#46;7&#37; &#40;n&#61;103&#41; were unemployed &#40;65 lost their job while 38 were disabled&#41;&#46; 8&#37; &#40;n&#61;16&#41; were retired&#46; The pCFS criteria are valid for the diagnosis in the clinical daily practice independently of other associated criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> Having a classification of patients with CFS will allow us to identify more homogeneous groups of patients&#44; candidates both for more individualized diagnostic and therapeutic guidelines and which allow for better expectations&#46; In order to correctly classify a patient with CFS&#44; we recommend a multidisciplinary approach&#46; In first place&#44; the CFS diagnosis must be confirmed &#40;family physician&#44; internal medicine specialist and&#47;or rheumatologist&#41;&#44; in order to then evaluate the existence of possible associated systemic diseases or chronic local processes that have a large differential diagnosis and&#44; finally&#44; to perform a precise diagnosis of the disease with a psychopathological background &#40;psychologist and&#47;or psychiatrist&#41;&#46; Having a clear diagnosis in each one of these 6 areas&#44; as well as the analysis of the chronology of symptoms or processes allows the inclusion of the patient into each one of the different classification subgroups&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">COPD&#58; chronic obstructive pulmonary disease&#59; CF&#58; chronic fatigue&#59; JAK2&#58; Janus Kinase 2&#59; OSA&#58; obstructive sleep apnea&#59; CFS&#58; chronic fatigue syndrome &#40;p&#58; primary&#59; s&#58; secondary&#41;&#59; CMPS&#58; chronic myeloproliferative syndrome&#59; ET&#58; essential thrombocytosis&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Classification subtypes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Primary disease &#40;n&#61;73&#47;199&#44; 36&#46;75&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Association autoimmune chronic thyroiditis &#40;n&#61;38&#47;199&#44; 19&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Cluster <span class="elsevierStyleSmallCaps">I</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">pCFS&#44; according to the Fukuda criteria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">None&#44; 90&#47;199 patients &#40;45&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#47;90 patients &#40;21&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Cluster <span class="elsevierStyleSmallCaps">II</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Idiopathic CF&#44; without having the Fukuda criteria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">None&#44; 36&#47;199 patients &#40;18&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&#47;36 patients &#40;13&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">Cluster IIIa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">sCFS autoimmune disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">17&#47;199 patients &#40;8&#46;5&#37;&#41;&#8226; 9 patients with primary Sj&#246;gren&#39;s syndrome<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#8226; 4 patients with polymyalgia rheumatica&#8226; 2 patients with systemic lupus erythematosus&#8226; 1 patient with Crohn&#39;s disease&#8226; 1 patient with Guillain&#8211;Barr&#233;&#8217;s syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#47;17 patients &#40;41&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Cluster IIIb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">sCFS to other medical entities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">40&#47;199 patients &#40;20&#46;1&#37;&#41;&#8226; 7 postchemotherapy patients&#8226; 6 patients due to drugs&#8226; 5 patients with severe OSA&#8226; 3 patients with a secreting hypophiseal microadenoma&#8226; 3 patients with hepatic cirrhosis&#8226; 3 patients with morbid obesity&#8226; 3 patients with severe iron deficiency&#8226; 3 patients with meopause&#8226; 2 patients with COPD&#8226; 2 patients with type TE JAK2 V617F CMPS&#8226; 1 patient with multiple myeloma&#8226; 1 patient with neuromuscular lung disease&#8226; 1 patient with severe myocardiopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#47;40 patients &#40;15&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Cluster IIIc&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">sCFS to psychopathologic abnormalities&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16&#47;199 patients &#40;8&#37;&#41;&#8226; 12 patients with depression&#8226; 3 patients with somatization&#8226; 1 patient with schizophrenia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#47;16 patients &#40;6&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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