Another CFSAC Violation

Posted on November 24, 2014 by Jennie Spotila

GavelToday I must report that once again, the CFS Advisory Committee violated federal law. This time, recommendations made by the Committee were illegally altered after the public meeting. The story of what happened, how I got it fixed (hopefully), and who might be responsible is another disturbing chapter in the saga of how HHS tries to disregard the law with impunity.

What Happened

After the recommendations from the March 2014 meeting were posted on the CFSAC website, Mary Dimmock and Denise Lopez-Majano noticed that something was wrong. The recommendations did not match what they recalled from watching the meeting. At first, we thought it was just the omission of references to the Canadian Consensus Criteria, but as I looked more carefully I found the changes went way beyond that.

The minutes of the March 11th CFSAC meeting capture the recommendations as voted on by the Committee. When I compared it to the recommendations actually sent to Secretary Sebelius by then-Chairman Dr. Gailen Marshall, they were dramatically different. The recommendation to increase research funding was completely eliminated, and most of the other recommendations had substantial changes as well. This table shows all of the changes made to CFSAC’s original recommendations.

The Federal Advisory Committee Act is a federal statute that specifies how advisory committees must operate. One of the biggest requirements is that recommendations must be discussed and voted upon in public. Both Dr. Marshall and Designated Federal Officer Dr. Nancy Lee are well aware of this requirement. Dr. Marshall even commented during the March meeting that “But we can’t make, you know, if I misspell something or I juxtaposition a word or two that’s fine, but we can’t change the words once we’re in agreement.” (Transcript, p. 95).

But this is precisely what occurred. At some point after the CFSAC meeting, the recommendations voted upon in public were changed. When CFSAC last violated this FACA provision in early 2013, I got help from Public Citizen to force HHS to correct the violation. This time, I took CFSAC on myself.

Fixing It

First, I contacted Chairman Dr. Sue Levine to ask for her help in restoring the original recommendations and sending them to the Secretary. I have no complaints about Dr. Levine’s attempt to correct the problem, especially because I was asking her to clean up someone else’s mess, but it became clear that she was encountering some difficulty or resistance from HHS. Then HHS posted a response to the illegal recommendations, and it was clear that more direct action was needed.

On September 29th, I wrote to the General Counsel of HHS and presented all the evidence of the FACA violation:

The attachments to this letter establish that the March 2014 recommendations of CFSAC were changed after the Committee’s public meeting and prior to those recommendations being sent to the Secretary, which is a patent violation of FACA’s requirement that recommendations be voted upon in public. This violation of statute is now compounded by the fact that the Department has responded to the illegally altered recommendations instead of the actual recommendations that the committee approved in an open meeting.

Specifically, on March 11, 2014, the CFSAC approved seven recommendations at its public meeting. Chairman Dr. Gailen Marshall sent a different set of recommendations to Secretary Sebelius on April 19, 2014. Dr. Marshall’s letter omits one recommendation in its entirety, and substantive and materially changes five of the remaining six recommendations. In response to my inquiry about these alterations, Dr. Marshall told me he recalls no “heavy editing” of the recommendations, but it is obvious that significant changes were made. . . .

There can be no dispute that changing the publicly approved recommendations of an advisory committee is a violation of FACA. Regardless of who altered the recommendations, or why they did so, the fact remains that the recommendations were altered outside the public view and without the involvement of the full committee. Moreover, the illegal behavior has since been compounded by the fact that the Department has responded to those illegally altered recommendations, not the recommendations actually approved by CFSAC.

I ask that you take immediate action to have the Department restore the committee’s original recommendations as recorded in the meeting minutes, so that it can consider and respond to the committee’s actual advice. I must also ask that you also ensure that CFSAC complies with FACA going forward, as this is the second time I have brought an indisputable FACA violation by the same committee to your attention.

I received no response.

But then on or about October 7th, the CFSAC website was changed. The illegal recommendations and the Department’s response to them was removed. A new version of the recommendations that is very close to what appears in the meeting minutes is now posted. However, I received no information or confirmation that these new recommendations were sent to the Secretary. So on October 17th, I wrote to the General Counsel again. This time, I said:

This letter will confirm my understanding that Secretary Burwell has received the actual recommendations approved by CFSAC at the March 2014 meeting for her consideration and response, If this is not the case, please notify me immediately.

I still have received no response. On November 21st, a letter from Secretary Burwell to Dr. Levine acknowledging receipt of the recommendations was posted to the CFSAC website, but that letter is dated June 20, 2014. That means Secretary Burwell is acknowledging receipt of the OLD recommendations. Neither the General Counsel’s office nor Dr. Levine have confirmed that the corrected recommendations have actually been sent to the Secretary.

Who Is Responsible

At the time I wrote to the General Counsel, I had no evidence about who changed the recommendations or why. To a certain degree, it didn’t matter because the important thing was to get those original recommendations restored. But I filed a FOIA request for documents and correspondence between the March 11th meeting and the April 19th letter to Secretary Sebelius with the illegal recommendations. And here is where it gets interesting.

Among the documents I received in response to that request were two versions of the recommendations. This first one corresponds very closely to what the CFSAC voted upon at the meeting, and it matches the restored version now on the CFSAC website. So there can be no doubt that the recommendations were captured correctly at the meeting.

This second document is a draft version of the letter to Secretary Sebelius. It is dated April 13, and as you can see there are many redactions (which I have appealed). You can see that the recommendations are now different from what the committee had approved. And it is the NAME of the document that is most important: “CFSAC Rec Letter 041314_GDM_NLee Redacted.”

This is strong (but circumstantial) evidence that Dr. Lee and Dr. Marshall cooperated in drafting this different version of the recommendations. We’ll see if I can get the redactions removed and whether that tells us anything more.

Implications and Consequences

It is extremely disturbing to me that this violation of FACA occurred. Dr. Lee and Dr. Marshall are very well aware that changing recommendations after a meeting is illegal. From that draft letter, it appears they did it anyway. I do not know why, but it is completely ridiculous and unacceptable. With Public Citizen’s help, I forced them to correct another FACA violation just the year before. This second violation was not an accident. The correct version existed and was in their possession, but they sent a different version to the Secretary. That April 19th letter went out over Dr. Marshall’s signature, making him responsible for its content. And Dr. Lee’s role as Designated Federal Officer is to ensure that CFSAC operates in compliance with FACA. They failed in fulfilling that responsibility.

I want to be very clear that Dr. Levine was put in the unfortunate position of trying to correct this problem. Furthermore, I have no evidence that any other members of CFSAC were aware that the recommendations were being changed. There is no correspondence indicating that they were consulted about a draft version or any changes. I assume they did exactly what I did when the recommendations were first published: glanced it over and assumed it was correct. It was only because two advocates looked more closely that we ever noticed the problem.

I had to spend an obscene amount of time and energy in accumulating evidence, writing these multiple letters, and trying to work within the system to correct this obvious and apparently intentional violation of federal law. This was time and energy that I did not have to spend. I had to carve out capacity for this matter while I was trying to analyze and respond to the P2P draft evidence review. This is wrong. I am too sick, and I damaged my health in getting this fixed.

Complying with FACA is not difficult, especially the basic requirement of using recommendations voted upon in public. The DFO and Chairman are responsible for ensuring the law is followed, and they are perfectly capable of doing so. And when the problem was brought to their attention, the correct and easy thing to do would be to simply fix it. I gave them every opportunity to do so before going to the General Counsel. A great deal of effort could have been avoided if the DFO and Chairman just did their jobs.

I copied the full CFSAC on both of my letters to the General Counsel, so they are aware of what was done in their names. I sincerely hope that they are as disturbed and outraged about this obvious violation of federal law as I am. I hope they will establish whether the corrected recommendations were actually sent to Secretary Burwell, and that they will do what they can to prevent future violations of FACA. It is beyond ridiculous that a disabled patient has to do this for them.

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CFSAC SNAFU

Posted on November 19, 2014 by Jennie Spotila

We’ve known about the CFS Advisory Committee meeting on December 3rd and 4th for awhile, but yesterday the details came out about the agenda and public comment. Judging from the advocates I’ve talked to, it’s not going over well.

If you want to offer public comment by telephone, you must register by Monday, November 24th at 5pm. If you want to submit written comments to the Committee, those comments are due November 24th at 5pm.

That’s right. You have less than a week to write public comment and submit it to the committee. This is an absurd requirement for the ME/CFS patient population, and HHS should be well aware of the level of disability we contend with. They should be well aware that giving us less than a week to write comments is unreasonable and unfair.

HHS may claim that we actually had more than a week’s notice, since a “save the date” note was put on the CFSAC website weeks ago. I have two responses to that. First, they cannot and should not assume that all patient advocates are watching the website or the CFSAC mailing list. That’s why CFSAC is required to provide public notice in the Federal Register 15 days before the meeting, and in the past the notice has been published much more in advance. Second, the Committee is asking for testimony on the topics of Centers of Excellence and patient registries. Yesterday was the first time that request became known, and therefore we have less than a week to prepare testimony on the requested topics.

There is dissatisfaction about the meeting agenda, as well. Brief comments on the P2P report on opioid use in chronic pain will be made by Dr. Sue Levine, and Bob Miller will speak briefly about the ME/CFS P2P meeting. I think it is significant that the NIH ex officio will not be making these presentations. Dr. Levine will also speak briefly on the “IOM Report Rollout.” I don’t know what will be covered in any of these presentations, but it will be followed by two hours of committee discussion.

There is no planned discussion of the AHRQ evidence review, although a source told me that such a discussion was requested by at least one member of the public. Also absent from the agenda is any discussion of NIH’s response to the Committee’s June recommendations. That response made it clear that NIH will not fund a central data repository, nor will it issue an RFA. So why is the Committee preparing a recommendation for Centers of Excellence funding when NIH has already refused to fund smaller scale recommendations?

Finally, there is great dissatisfaction about the scheduling of this meeting one week before P2P. It’s the holidays, a very challenging time of year for patients because of the extra demands on time and energy. Holding the P2P meeting in December is bad enough. Stacking a CFSAC meeting on top of it – just one week before – is a heavy burden for patients to bear.

I’ve been asked if we should boycott the CFSAC meeting. I think if you only have the energy and capacity to pay attention to one meeting, then pay attention to P2P. Watch that meeting online and submit comments and questions through the mechanism NIH has said would be provided. The P2P meeting and report is MUCH more important than this upcoming CFSAC meeting. But if you are able to do so, watch the CFSAC meeting and submit public comment.

A patient relayed this story to me from a CFSAC meeting some time ago: When she requested an accommodation at a CFSAC meeting, an HHS employee told her that if she was so sick that she needed this particular accommodation, then she shouldn’t be attending the meeting.

This is the attitude that patients hear in circumstances like this one. Too sick to write public comment in a week? Too sick to watch meetings via webinar in two weeks running? Then you shouldn’t be participating.

I know that CFSAC members care about the ME/CFS patient population. Serving on CFSAC is no picnic, but they do it because they want to help people with this disease. But let’s be clear. When CFSAC gives short notice of comment requirements, when meetings are scheduled in such a way that it becomes impossible for patients to attend, what we hear is that we don’t matter. Whatever the good intentions of CFSAC members may be, the signal to the ME/CFS community is that if you are too sick to keep up, then your voice doesn’t matter. And that’s just not right.

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P2P: Not This Science

Posted on November 17, 2014 by Jennie Spotila
from lookhuman.com

from lookhuman.com

The P2P Workshop agenda focuses on a few broad categories of ME/CFS research: characteristics of the ME/CFS population; fostering innovative research; presentation and diagnosis in clinic; and, tools and measures for diagnosis and outcomes. Yet even with the late addition of Dr. Mady Hornig to discuss the immune system and ME/CFS, the Workshop agenda still glosses over many topics in etiology, diagnosis and treatment. This “science lite” approach will hamstring the non-ME/CFS expert Panel, and practically guarantees deficiencies in the final Workshop report.

It doesn’t have to be this way. The P2P approach stands in stark contrast to the science presented at the 2011 State of the Knowledge meeting. That workshop dove deep into infectious disease, systems biology, immunology, neurology, exercise physiology, diagnosis and biomarkers, and treatments. While there was no panel to produce a set of recommendations, the meeting participants identified a number of opportunities for advancing ME/CFS research, including: define and standardize case definition and terminology; conduct more cross-system research; develop standard procedures and common data elements across the field; address gaps in study design, biomarkers and clinical trials, outcome measures, and reproducibility; create a centralized data repository; and attract new investigators. All of these issues remain unaddressed and unsolved three years later.

Of course, we need not look back three years for examinations of ME/CFS science and priorities. For example, the May 2014 Invest in ME conference focused on autoimmunity, infection, immunological biomarkers, brain imaging, the autonomic nervous system, markers for post-exertional malaise, and diagnostic and treatment strategies. Then there was the March 2014 Stanford ME/CFS Symposium, which examined epidemiology, cytokine and gene expression patterns, cardiovascular aging, MRI and EEG findings, inflammatory/autoimmune profiles, and microbial investigations.

Finally, there was the March 2014 IACFS/ME Meeting: Translating Science into Clinical Care. This four day meeting was even more comprehensive than the 2011 State of the Knowledge workshop, covering immunology, exercise and metabolism, treatments, orthostatic intolerance, pediatric issues, autoimmunity, biomarker and pathogenesis findings, case definition issues, brain function and imaging, and much more. There is a detailed summary available, as well as Dr. Komaroff’s conference summary talk.

Replication of these scientific meetings is not required, or even necessarily desirable, for ME/CFS experts to examine the field and identify research priorities. Each meeting should build upon and expand what came before. But of course, the P2P Workshop will not ask ME/CFS experts to do this.

The P2P Workshop will ask non-ME/CFS experts to identify future research priorities without giving them all the necessary information to do so. All along, we have been assured by Dr. Susan Maier (NIH), Dr. Beth Collins-Sharp (formerly AHRQ), and others that the non-ME/CFS expert panel will receive the evidence review survey of the literature and presentations by ME/CFS experts, and that the two combined will adequately equip them to pronounce judgment on the future direction of ME/CFS research. But this is not the case.

The evidence review ignored or excluded the science on biomarkers, pathophysiology, some promising treatments, and the case definition conundrum. And the P2P Workshop agenda appears to be completely devoid of science on brain imaging, autoimmunity, orthostatic intolerance, and pediatric issues (to name a few topics). For example, Dr. Chris Snell is speaking about lessons from current treatments and clinical trials, not exercise abnormalities. If there is any discussion of cognitive dysfunction, it will only be because a speaker manages to shoehorn it into his/her talk.

How on earth can a panel of non-ME/CFS experts, presented with very limited information on the science and working over just a few days, produce recommendations for future research that will actually move the field forward? And if they manage somehow to do so, how will the recommendations be any different from what emerged from the 2011 State of the Knowledge Workshop?

I do not object to the use of non-ME/CFS experts in all cases or circumstances. I do not believe that this disease is too difficult for outsiders to understand. For example, the non-ME/CFS experts on the IOM committee have had the benefit of more than a year’s immersion in the literature with eight experts in the room to provide perspective, and this will hopefully have a positive impact on the outcome.

But for the 100% non-ME/CFS expert Panel to grasp this complex and controversial knowledge base in the very limited time they have to produce their report is an extraordinary challenge. It would be a challenge even if they were thoroughly immersed in that knowledge base through the evidence review and Workshop. As should be abundantly clear, I do not believe they will be immersed in the knowledge base. The Panel has been given a fundamentally flawed and imbalanced evidence review (compiled and written by other non-ME/CFS experts). They will hear a narrow and skewed presentation of ME/CFS science at the Workshop, despite the inclusion of some highly qualified speakers.

The P2P Panel’s report may not be our worst fears come to life, but there is a significant risk that it will not produce recommendations that will propel ME/CFS research forward – if for no other reason than the Panel will not actually be shown the full research landscape. How can you draw an accurate map if you don’t actually see your starting point or the landscape through which you must navigate? The P2P situation is a bit like asking someone to chart a path from point A to point B, but not telling them about the 4,000 foot change in altitude in between, and also not giving them the proper footwear for the hike.

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P2P and Dr. Francis Collins

Posted on November 10, 2014 by Jennie Spotila

indexOn January 3, 2014, just three days before the P2P Working Group meeting, a troubling series of emails was exchanged among NIH leadership. These emails show confusion at the leadership level about the ME/CFS P2P and IOM efforts, and a narrow concern from Dr. Francis Collins himself about the topics for P2P.

I obtained these emails through FOIA. I’ve posted the emails for you to read in their entirety, but the organization can be confusing. The emails are also heavily redacted, which I have appealed. In this post, I’m using a narrative format because it is critically important that every ME/CFS researcher and advocate understand this story. Bottom line? No one in charge seemed to understand what was going on, and the implications of that are frightening.

On January 3rd, Cort Johnson’s article about the dramatic decline in NIH’s commitment to ME/CFS over time appeared on ProHealth, and a note about the article appeared in the NIH internal news summary that day. This prompted Dr. David Murray (Director of the Office of Disease Prevention) to email his staff to ask for their input on a draft email to Dr. Francis Collins about the P2P meeting. The draft is redacted, as is a comment from staff member Jody Engel.

Dr. Murray then sent the following email to Dr. Collins (copying four other staff members in the Office of the Director):

I noticed the item in today’s news briefing regarding chronic fatigue syndrome. The report suggested that NIH was falling behind in this area.

Let me alert you that ODP has been planning a workshop on Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) as part of its Pathways to Prevention workshop series for more than a year. Jim Anderson was involved in the initial proposal development and selection of the Working Group members. Janine Clayton and Susan Maier at ORWH have been involved from the outset. The first meeting of the Working Group is scheduled for Monday, January 6 and the target date for the workshop is Fall 2014.

We generally don’t publicize these workshops until they are further along in the planning and have HHS approval, but I wanted to share this with you so you were aware.

This is pure politics. The planned P2P Workshop in no way changes or addresses the decline in funding that Cort discussed in his article. The Workshop does nothing to avert the trajectory of NIH falling behind on ME/CFS, especially in light of everything else NIH is refusing to do. Dr. Murray saw an opportunity to put his office’s work forward, and he did.

Almost immediately, Dr. James Anderson emailed Dr. Murray and said,

Remind me- the goal of the ODP WS is to provide a research definition for ME/CSF [sic]. We are not wandering outside that box. The IOM meeting [redacted].

This is remarkable. NIH had been saying quite clearly at CFSAC meetings that the purpose of the workshop was not to come up with a research definition. Yet here is the Director of Program Coordination, Planning, and Strategic Initiatives saying the precise opposite. Before replying, Dr. Murray turned again to staffer Paris Watson and said, “I need to clarify the purpose of the workshop. It is supposed to be used to [redacted].” Is Dr. Murray asking Watson because he doesn’t know the purpose of the workshop?! This is precisely what we’ve already documented: the purpose of the P2P meeting has shifted over time and NIH has made contradictory statements about it. Apparently, this is true internally as well.

Shortly thereafter, Dr. Murray responded to Dr. Anderson, saying in part, “The goal is to address methodological issues that are holding up research in this area. So the working group will tackle the issue of what diagnostic criteria should be used in research for ME/CSF [sic].” Anderson then replied:

I think Francis needs a follow-up email explaining how the NIH and IOM goals are different. Our goal is to provide a more useful definition of ME/CSF [sic] so that our research investments produce the highest quality and valid results. [redacted]

I don’t think any ME/CFS researcher or advocate is under the illusion that the Director of NIH has our disease forefront on his mind or agenda. There’s not enough money involved for that to be the case. But I find it troubling that Dr. Collins needed an explanation of how the “NIH and IOM goals are different.” Given the controversy, and given NIH’s role as a primary funder of both initiatives, shouldn’t someone have already briefed Dr. Collins on this – or at least his senior leadership staff?

Dr. Murray turned his attention to drafting a follow-up email to Dr. Collins, again relying on Paris Watson and Dr. Susan Maier. There are some significant and troubling statements in the resulting email:

Jim Anderson suggested that I follow my earlier note to [redacted].

Our P2P workshop will review the various definitions for ME/CFS that have been used in research studies to clarify the type of patients that are captured under each definition and how those patients respond to various therapeutic options. This will inform future research by providing a better understanding of the implications of choosing one definition over another as studies are being designed. Our audience will be researchers working in ME/CFS.

The IOM effort will also review the various definitions for ME/CFS but their goal is to recommend diagnostic criteria and case definitions for clinical care. Their audience will be health providers, patients, and caregivers, not researchers.

Our planning had been underway for sometime when we learned of IOM’s interest in this topic. We have been communicating with them to avoid duplication of effort. They have invited Susan Maier from ORWH to their first meeting to discuss our P2P Workshop “in an effort to minimize overlap and maximize synergy.”

First, note the promise that P2P will clarify which patients are captured under each case definition and how that affects response to treatment. Whatever the plan was in January 2014, we now know that P2P will not do this. The evidence review made no such distinctions and lumped all the case definitions together. There is no indication that anyone is going to address the question of how case definition predicts response to treatments. Second, note the statement that IOM’s audience is not researchers. Does this signal an intention that researchers not use the IOM output? Fukuda was intended as a research definition, but it’s been used clinically for 20 years. If IOM produces an accurate and precise case definition, shouldn’t researchers be the exact audience that needs to pay attention to that? Finally, Dr. Murray admits that the P2P planning was underway for “sometime” when they learned of the IOM’s “interest” in the topic. In other words, there was NO coordination between the P2P and IOM ideas, as many of us suspected.

Finally, Dr. Francis Collins responded to the emails from Dr. Murray:

Thanks for the heads up. I hope there will be some attention to the microbiome as part of this CFS workshop.

I will admit that when I first read this email in the FOIA packet, my jaw dropped. Out of all the ME/CFS issues, including case definition (which Dr. Collins himself personally noted was a problem at the 2011 State of the Knowledge Workshop), what he asked about in January 2014 is the microbiome. Why?

I can only speculate, but perhaps the answer lies in what Dr. Ian Lipkin told Mindy Kitei in May 2014. Dr. Lipkin, whose effort to find funding for his ME/CFS microbiome study is well-known, said, “I’m on the advisory committee for Francis Collins, and I can tell you that Francis Collins, the director of the NIH, believes that chronic fatigue syndrome is a problem.” Have Drs. Lipkin and Collins discussed the microbiome study? Have they discussed the poor scores given to Dr. Lipkin’s grant proposal by a reviewer who said ME/CFS was a psychosomatic illness? Personally, I hope they have discussed it, but for this topic to be Dr. Collins’ “hope” for the workshop strikes me as myopic, at best.

As one would expect, an email from the Director of NIH received immediate attention. Dr. Murray quickly asked Dr. Maier and Paris Watson if the microbiome was in the plans for the P2P workshop. Dr. Maier responded, “I am sure that the microbiome will be discussed as part of the scientific content at the actual workshop, however, the purpose of the P2P really is to help determine the extent of evidence surrounding the case definitions . . . “ Dr. Maier also quickly told Dr. Murray and Dr. Anderson that “Microbiome is playing a larger role in ME/CFS research, with at least 2 of 16 projects following this approach as the primary objective, and others with a smaller focus on microbiome in general.”

Simultaneously, Deputy Director of NIH Dr. Lawrence Tabak emailed, “As I recall HHS was planning on sponsoring a workshop on this in FY14 that NIH is a co-sponsor of; Janine [Clayton] may know the details – if not I can find out.” And now confusion really spins out of control.

Dr. Murray, now quite flummoxed, emailed staff member Wilma Peterman Cross in part, “Francis raised the issue of the microbiome and Larry raised the specter of yet another workshop. I am trying to find out if this ‘other workshop’ is the IOM meeting. I hadn’t intended to spend most of my morning on this . . . ” Turning again to Dr. Maier and Ms. Watson, Dr. Murray asked, “Do either of you have information on this? Is this the IOM workshop that the 3 of us have been trading notes about this am? Or is there a third workshop being developed that I haven’t heard of.”

Ok, let’s pause for a minute. NIH is co-sponsoring the IOM study under their contract with the National Academy. The IOM contract had been controversial for months, and Dr. Maier was scheduled to speak at the IOM meeting in just three weeks. Yet the Deputy Director of NIH had no idea what is going on with it, Dr. Collins needed an explanation of the difference between IOM and P2P, and now Dr. Murray had to scramble to figure out if there was a third meeting he was not aware of. Am I surprised? No. Is it disheartening to see how far off the radar ME/CFS is? Absolutely.

Dr. Maier, one of the only NIH staffers who appeared to know what was going on, replied, “Yes, the 2014 workshop from HHS is the IOM workshop/study. Those are the only 2 I know about other than a potential in house one at NINDS looking at brain fog in general.” Dr. Murray then sent a final email to Dr. Collins and Dr. Tabak, repeating what he said before about the P2P vs. IOM effort and saying, “Francis…At least two currently funded projects on ME/CFS address the microbiome. That topic is very likely to come up at the P2P workshop in the fall.” Of course, we now know that the microbiome is just one of many categories of ME/CFS science that will not be discussed at the Workshop.

These emails are a telling snapshot of NIH leadership’s scramble, on the eve of the P2P Working Group planning meeting, to figure out the purpose of the P2P meeting and its difference from the IOM study. Even the Director of the ODP – the office charged with running the P2P Workshop – does not seem to understand the purpose of the Workshop and how it fit (or failed to fit) with other NIH efforts.

Furthermore, Dr. Collins’ only response to the blurb from Dr. Murray about the P2P Workshop is to say that he hopes the microbiome will be covered. Even if Dr. Collins is not tracking ME/CFS (and I doubt he is), how could the microbiome be the foremost issue in his mind? As I said, Dr. Collins attended the 2011 State of the Knowledge Workshop and acknowledged the importance of resolving the case definition issues. He sat and listened to Dr. Suzanne Vernon summarize the gaps in research and the issues that needed attention. But in January 2014, he only mentioned the microbiome – a topic that his colleague Dr. Ian Lipkin is interested in investigating.

I have no doubt that the P2P Workshop will open with statements from Dr. Anderson and Dr. Murray that this is a significant demonstration of NIH’s commitment to ME/CFS patients and research. That is how these meetings always begin. And I would love to hope that the Workshop marks a new chapter of increased attention and funding for ME/CFS at NIH. But given the confusion among leadership in January 2014, I have some trouble believing this to be a realistic hope.

This whole email exchange started because of the news item claiming that NIH was falling behind in its commitment to ME/CFS. Dr. Murray basically says Hey Dr. Collins, it’s not true because we’re planning a meeting. And then for three hours, leadership muddles around trying to figure out what exactly the meeting is about and how it differs from the IOM contract. And the only thing Dr. Collins says is, I just hope you cover the microbiome.

It’s not just the confusion that bothers me, or even the narrow focus on one researcher’s interest in the microbiome. It’s the mindset reflected in that first email from Dr. Murray to Dr. Collins. It’s the bureaucratic mindset that responds to evidence of NIH’s failure to make any progress on a costly and disabling disease with “We’re having a meeting.”

The P2P Workshop represents an opportunity to get it right. It could address the problems that are holding ME/CFS research back. That may even be the intention of staff like Dr. Susan Maier, and it is certainly the intention of the ME/CFS expert members of the Working Group. But given the deeply flawed evidence review, the closed door selection of Panelists, the exclusion of many experts and important topics, and the inclusion of speakers who believe ME/CFS is a functional somatic syndrome, is it realistic to believe that the Workshop will start a new chapter and begin to make up for the stagnation of funding? What do you think?

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P2P: The Disinvite List

Posted on November 6, 2014 by Jennie Spotila

not_invited

UPDATED November 10 11, 2014 (see below)

Last week, I focused on the problematic choice of several speakers for the P2P Workshop. Today, we’re going to focus on the speakers who were NOT invited to the Workshop.

How do I know who was dis-invited? I received this draft agenda for the Workshop through FOIA, and according to documents obtained by Jeannette Burmeister through FOIA, it appears to have been drafted in concert with the Working Group meeting in January 2014. It is important to note that this document may not have been shared with the non-federal members of the Working Group, as several told me they had never seen it.

According to the Draft Agenda document, the following speakers were suggested but do not appear on the current Workshop agenda (I’ve included links for the unfamiliar names):

  • Valerie Anderson (has co-authored two papers with Dr. Leonard Jason)
  • Dr. Italo Biaggioni
  • Dr. Gordon Broderick
  • Dr. David Cella (expert in patient reported outcomes)
  • Dr. Dane Cook
  • Dr. Mary Ann Fletcher
  • Dr. Jacob Furst (co-authored two papers with Dr. Jason on case definition)
  • Dr. John Gore (imaging expert)
  • Dr. Arthur Hartz
  • Dr. Mady Hornig
  • Dr. Anthony Komaroff
  • Dr. Gudrun Lange
  • Dr. Kathy Light
  • Dr. Ian Lipkin
  • Dr. Dana March
  • Dr. Vivian Pinn (former director of Office of Research on Women’s Health at NIH)
  • Dr. Satish Raj (co-authored papers with Dr. Italo Biaggioni)
  • Dr. Judith Richman (co-authored two papers with Dr. Jason)
  • Dr. Peter Rowe
  • Dr. Dikoma Shungu
  • Dr. Julian Stewart
  • Dr. Jon-Kar Zubieta (neurobiological basis of mood disorders)
  • Patient speakers: Denise Lopez-Majano, Jennifer Spotila, Dr. Lily Chu

There are fourteen ME/CFS expert researchers on that list, eighteen if you count Dr. Jason’s and Dr. Biaggioni’s co-authors. FOURTEEN experts in ME/CFS biomarkers, pathophysiology, and clinical care who were originally proposed as speakers and who ultimately did not make the list. (Update: a commenter rightly pointed out that it is possible these experts were invited and declined. I’ve sent inquiries to see if I can determine how many may have declined. I’ll report what I find out.)

And to bring it full circle to last week’s post, three speakers on the current agenda were not originally proposed: Dr. Andreas Kogelnik, Dr. Niloofar Afari, and Dr. Daniel Clauw.

Here’s the $64,000 question: who at NIH decided it was a good idea to invite Dr. Afari and Dr. Clauw to address how to foster innovative research in place of, for example, systems networking pioneer Dr. Gordon Broderick or long-view Dr. Anthony Komaroff or infection/immune guru Dr. Ian Lipkin?

How does this make any sense for a Workshop that will charge a group of non-ME/CFS experts with making recommendations on future ME/CFS research?

UPDATE November 10 11, 2014: I reached out to the ME/CFS experts on the original list to see if any had been invited and declined. Of the ten who responded, six were not invited and three were invited and declined. One was invited and accepted, and a source told me that the agenda will be finalized soon, so we may see some changes.

Posted in Advocacy, Research | Tagged , , , , , , , | 22 Comments

Delay

Posted on November 3, 2014 by Jennie Spotila

I have been laid low by an infection, and now by the antibiotics I’m taking to treat the infection. So it will be a few days before I post the next few entries on P2P – but stay tuned because it may leave you looking like this:

are-you-serious-wtf-meme-baby-face

Posted in Occupying | Tagged , , , | 1 Comment

P2P Agenda: What the Huh?

Posted on October 31, 2014 by Jennie Spotila

Less than six weeks from the NIH P2P Workshop on ME/CFS, and we now have an agenda with speakers and talk titles.  So is it good or bad?

I reached out to the six ME/CFS members of the Working Groups for their thoughts on the agenda. Dr. Suzanne Vernon told me, “[T]he agenda uses a comparative effectiveness approach and format to address the key questions initially posed by the working group.  I think they’ve invited a relativity good mix of speakers with a range of expertise and experience to help inform the panel.” Three members did not respond and one responded but did not comment. The sixth member of the Working Group would only comment off the record, and said that some of the line up was solid but some of it was disappointing.

I agree that there are some bona fide experts on the agenda, speakers like Dr. Jason, Dr. Nacul, Dr. Klimas, and Dr. Snell. They are obvious choices for their expertise. But then there are some speakers that made me stop and think “What the what? Are you kidding me?”

The Problematic Cluster

The second main topic of the Workshop is titled: “Given the unique challenges of ME/CFS, how can we foster innovative research to enhance the development of treatments for patients?” This is a critical question, and brings to mind things like centralized data repositories, the case definition issue, drug repurposing, or systems networking and bioinformatics work like that of Dr. Gordon Broderick or Dr. Patrick McGowan.

Instead, this section focuses on studying diseases other than ME/CFS as a way to back into ME/CFS results. I’m fully in favor of out of the box thinking and learning from other scientific areas. Autoimmune and autoinflammatory diseases come to mind as one promising area. But that’s not what we’ll hear at the P2P Workshop.

The Speakers

The three speakers for this section are Dr. Dedra Buchwald, Dr. Dan Clauw, and Dr. Niloofar Afari. If anyone thought that psychosocial theories and functional somatic syndromes would not make an appearance at the Workshop, I’m afraid I must correct your false workshop belief.

Dr. Dedra Buchwald has been a CFS researcher for years, heading one of the ill-fated NIH CFS Research Centers more than a decade ago. She has built a large twin registry at the University of Washington, and has developed broad expertise in Native American health issues and studies. But her work on chronic fatigue syndrome is controversial.

Many of Dr. Buchwald’s publications focus on the predisposing role of trauma in CFS, the high rates of depression and anxiety in CFS, and an integrative view that blends it with FM and a broad view of the illness.

As just one example, Dr. Buchwald co-authored a topic summary on CFS with Dr. Craig Sawchuk (who did his postdoc work with Dr. Buchwald and was co-director of the Harborview Chronic Fatigue Clinic). This summary includes many elements from the integrative or psychosocial model of CFS. Under risk factors, the guide states, “Premorbid psychiatric illness can increase risk for CFS, including personality traits such as ‘action-proneness’ and emotional instability,” and “Historical patterns of persistent over- and underactivity levels may confer risk for CFS in adulthood.” For treatment, pharmacotherapies are not recommended, except for comorbid disorders. “CBT and graduated exercise therapy have the greatest cost effectiveness and probability of yielding symptom and functional improvements.” Exercise begins with 5-minute periods of aerobic exercise five times a week. CBT is “designed to modify thoughts, behaviors, and environmental contingencies that are maintaining or exacerbating symptoms and impairments.” Finally, “Treatment-resistant patients should be referred to a mental health professional.”

These kinds of recommendations are familiar to every patient with ME/CFS. It is a view of the disease based on disordered patient perception and secondary deconditioning. This view persists in the face of thousands of papers to the contrary. All the contrary data – and there is a lot of it – is ignored.

Dr. Dan Clauw is Director of the Chronic Pain and Fatigue Research Center at the University of Michigan. His focus has been fibromylagia and the “chronic multisymptom illnesses,” such as CFS and GWI, that accompany it.  Dr. Clauw treats FM with a balanced approach using both medication and exercise/CBT. He has extensive connections to pharmaceutical companies, including funding from Eli Lily to create FibroGuide, a CBT program for people with FM.

Dr. Clauw spoke at the P2P Workshop on Opioids and Chronic Pain at the end of September, and some of his comments were surprising, to say the least. Using the term “fibromyalgianess,” Dr. Clauw favors using a self-report questionnaire rather than “a stupid tender point count.” Acknowledging that he was being provocative, Dr. Clauw said, “I view opioids as the Kardashians in the chronic pain field. And the reason I say that is that I think they receive an undue amount of attention. We should really have just stopped the meeting after we went through all those slides showing that they’re not efficacious in chronic pain.” Then there was this gem:

I also think we can probably prevent the transition from chronic nociceptive pain to chronic centralized pain. I think that that’s something that we likely…. I can with a reasonable degree of accuracy, I can look at someone’s medical record at age 20 and tell you if they’re going to develop fibromyalgia at age 40. They would already have 2 or 3 regional pain syndromes by their early 20s and they’re marching down this course and we don’t do anything right now to try to do primary or secondary prevention and I think  most of us feel that fibromyalgia’s just sort of the end of a continuum.

I appreciate that Dr. Clauw is saying that early and adequate treatment of pain can prevent that pain from becoming chronic and refractory to treatment. But claiming he can look at the chart of a 20 year old and predict whether they will have FM? Really? Do you know what my chart looked like up until age 26? Perfectly clean, healthy, with a few short acute infections that fully resolved, and absolutely no other medical or psychological problems of any kind. Then I got sick with an apparent viral infection and here I am 20 years later, in my 40s, with ME/CFS and FM and POTS. The claim that this could be predicted from my chart at age 20 is ridiculous.

Dr. Niloofar Afari is a psychologist who was Associate Director of Dr. Buchwald’s center from 1998 to 2006, and is now at UC San Diego. Much of her work has focused on twin registry projects and treating a number of pain conditions. One of her more recent papers is an examination of the association between psychological trauma and functional somatic syndromes like CFS and FM. The study found that people with trauma were 2.7 times more likely to have a functional somatic syndrome, and CFS was included in that category.

Drs. Buchwald, Clauw and Afari overlap each other to a great degree. They have co-authored papers together, they’ve worked together. Their views on ME/CFS are at the opposite end of the spectrum from researchers like Dr. Klimas, Dr. Jason or Dr. Montoya. Having an opposite view does not automatically disqualify them from speaking at the Workshop, in my opinion. But their presence on the agenda, especially in the context of fostering innovative research, is a huge red flag.

We already have a systematic evidence review that combined eight ME and CFS case definitions, despite stated misgivings that it could include people without the disease. Layered on that, we have this attempt to create innovative research by looking at overlapping and co-morbid conditions – but only functional somatic syndromes. The Workshop is not going to look at the co-morbidities of orthostatic intolerance, Lyme disease, reactivated viral infections, cancers, or Ehlers-Danlos syndrome. Nor is it going to draw clean lines around ME/CFS for research purposes. If anything, this paves the way for broader cohorts. ME/CFS research and the care of ME/CFS patients will not be advanced through this dangerous sinkhole of examining trauma or lumping our already overly broad category into the shapeless mass of “fibromyalgianess.” Studying so-called functional somatic syndromes is not innovative research; this approach is outdated, and brings confusion instead of clarity to ME/CFS research.

The Overlap

There’s another layer of weird overlap, in addition to the research/publishing overlap of Buchwald, Clauw and Afari.

In 2012, NIH hosted a Workshop on Overlapping Chronic Pain Conditions. The meeting was co-chaired by Dr. Clauw and Dr. Beth Unger. Among the talks were:

  • Overview of the meeting and chronic overlapping pain conditions by Dr. Clauw
  • Understanding chronic overlapping pain conditions: Lessons learned from twin studies by Dr. Afari
  • What has the CDC’s ME/CFS program taught us about overlapping conditions? by Dr. Unger
  • Overlapping pain conditions: Disparities and special populations by Dr. Carmen Green (University of Michigan)

That last talk is important, because Dr. Carmen Green is the chairman of our P2P Panel. Dr. Green is on the faculty of the University of Michigan, as is Dr. Clauw. She is also a member of the Interagency Pain Research Coordinating Committee (IPRCC). Dr. Green and Dr. Unger serve together on the subcommittee on Public Health Disparities for the IPRCC.

Does this seem weird? One section of the P2P Workshop is being given to Buchwald, Clauw and Afari, who have published together and share a particular disease view of ME/CFS. Then we throw in this 2012 meeting, which Dr. Unger co-chaired with Dr. Clauw, and where she spoke about what CDC’s program on ME/CFS can teach us about overlapping conditions. Also presenting at that meeting was Dr. Green, who not only serves on the IPRCC, but also serves on a subcommittee of IPRCC with Dr. Unger.

ME/CFS is a small field, and there is going to be overlap among researchers, meetings, and programs. That overlap does not in and of itself disqualify anyone from participating in other activities like this Workshop. But recall that the P2P Panel is selected by NIH to be ME/CFS bias-free. The idea is to form an impartial “jury” that has not researched or treated people with ME/CFS. We already have a high obstacle given that 85% of doctors believe CFS is wholly or partially psychological, so finding a blank slate group of experts was always going to be a challenge.

We can’t know for sure what Dr. Green’s views are, especially as the Panel selection process has been completely hidden from the public. She may or may not share views with Unger, Clauw, Afari or Buchwald. Maybe she thinks they’re wrong, or maybe she is keeping an open mind and will listen to all the speakers. But the overlaps here are a cause for concern.

Now someone could very well say, Hey, you’re not complaining about the overlap between Klimas and Natelson on the IOM committee and this meeting. Or the connections between Dr. Jason, Dr. Taylor and Ms. Brown. But Dr. Green is the P2P Panel Chair, and so her connections with some speakers who view CFS as part of a broader morass of fatigue and pain conditions is a legitimate concern.

Old Guard

This looks like old guard NIH. That “innovative research” section represents the same disease view that filled the CFS Special Emphasis Panel with experts on TMJ and FM. It is the disease view that refuses to acknowledge the muddle of case definitions, including the disproportionate selection of people with primary depression. This is the disease view that, as stated on the draft agenda I received through FOIA, has Dr. Susan Maier speaking about “overwhelming fatigue or malaise as a public health problem.”

The first part of the equation is the fundamentally flawed evidence review that ignored all of the most promising biomarker and treatment research. Add that to this Workshop which has an entire section based on the innovative old view of CFS as a condition perpetuated by deconditioning and emotional problems. What can we expect the sum of those two factors to be? Speakers like Klimas, Snell, Jason and others have an uphill climb to present all the evidence that contradicts this old guard view, and succeed in convincing the unknown Panelists that it is time for NIH to move forward.

Posted in Advocacy, Research | Tagged , , , , , , , , , , | 49 Comments

Illness Beliefs (or Why I Am Not an ME/CFS Activist)

Posted on October 21, 2014 by Jennie Spotila

Today, Joe Landson shares his thoughts on how the false illness beliefs (or even cognitive bias) among scientists is holding our field back. Joe says it is time to tear down the walls and think horizontally – to the horizon, even. Let’s look at what is actually in front of us, and not what we expect to see.

I am not an ME/CFS activist because of incorrect illness beliefs. Yes, incorrect illness beliefs – as I see it, they’re the main challenge in ME/CFS. No, no, not our beliefs as patients – the Wessely School’s notions that our beliefs make us sick are absurd, and always were. No, I mean incorrect medical ideas generally, specifically ideas of what makes an illness ‘real’ or not, or what makes an illness at all.

Let me explain. No, there is too much, let me sum up. For a very long time, doctors and researchers defined an illness as ‘organic’ by the tissue damage they could see. For example, the tumors they could see, feel and biopsy made cancer ‘real’. It was damage to an organ; hence, organic.

However this approach has had some treatment limitations. Cut the tumor out; more grow back. Eventually, medicos devised treatments to shrink the tumors and make them less likely to return: namely, chemotherapy and radiation.

For decades, treatment of cancer and other organic diseases generally improved. However treatment of those other diseases, those without detectable organic damage and called functional disorders, was decidedly mixed. It’s fair to say that treatment philosophies for those invisible functional disorders often (though not always) featured extraordinary contempt for the illness and the patient. From Dr. Lewis Yealland’s electrocution of World War One shell-shock patients to the Wessely School’s use of forced exercise for ME/CFS, it seems that contempt generally wins. Contempt is quick and seems to produce clear results… much the same way that cutting out the tumor seemed to ‘cure’ the cancer. Except it didn’t, and still doesn’t.

Meanwhile cancer treatment has evolved. As I write this, the Food and Drug Administration (FDA) is fast tracking radical new immunotherapy for cancer. Immunotherapy doesn’t affect the organic damage directly; rather, it blocks, damps or corrects the immune signals that encourage the tumors or other organic damage to occur. It’s about the signals – the signals that tell the organic damage to start or stop.

This begs the question: What about immune signals that don’t produce organic damage? What about illnesses with a chronic pattern of bad immune signals, but no apparent organic damage at all? What if the signal pattern is the damage?

This mental leap surmounts the wall medicos have built between organic diseases and functional disorders. Both types of illness can potentially be treated the same way – perhaps even with the same drugs, if the Rituximab studies are any indication. Moreover, doctors now can sometimes detect and treat disease before the organic damage ever happens.

This shift in medical beliefs is going on all around us, but not for us, because most of the official gatekeepers of ME/CFS are working so very hard to keep this illness category locked in place, endlessly describing empirical symptoms instead of genuinely investigating their underlying mechanisms. In the constant balancing act in life between control and progress, they side with control. Rather than waste time arguing with these gatekeepers, I’d like to do an end run around them, and point out that all these invisible functional disorders are ‘organic’, if we only change our minds and amend what we mean by ‘organic’. Organic can be a pattern of immune signals rather than the organ damage of yesteryear. Similarly I think our well-meaning friends who insist our bad signals must be located in our brains – organ damage all over again – are thinking too narrowly. Certainly our brains are deeply affected, but that doesn’t mean the bad signals start or end there.

When I grow up, I want to be a bomb-throwing medical anarchist. For NSA-types scanning this blog, no, I don’t mean actual bombs. I want to blow up medical ideas of what ‘organic disease’ really means. I want to explode the borders of medicine – the borders between organic disease and functional disorders; the borders between medicine and psychiatry generally. But just to keep you nervous, internet police, I can and will say that in Arabic if I have to!

This is a long way of explaining why I’m not an ME/CFS activist, per se. I think trying to maintain ME/CFS as a category is a narrow goal and a rigged game – rigged because our government seems dedicated to ‘evidence-based’ approaches to ME/CFS, rather than re-imagining the evidence we have. I think arguing over this or that definition of ME, or CFS, is a poor use of our time and energy, because none of the definitions extant define the immune signals that I suspect (but can’t prove yet) make us sick. To me, all the tiny, empirical functional categories, from bipolar disorder to Morgellon’s, are empty shells of outdated thinking. In pure immune research, someone is finding those signals as we speak – it’s just not labeled ME/CFS research, or Morgellon’s or bipolar research. At least, not yet.

We should seek this research out, celebrate and promote it. We should do as some are already doing, and point out both the sorry current state of – and the immense future possibilities for – almost all the invisible illnesses. Most of all we should see and portray the invisible illnesses as part of a continuum of immune signaling disorders, beyond their separate, and inherently unequal, empirical definitions.

 

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Comments on P2P Systematic Evidence Review

Posted on October 18, 2014 by Jennie Spotila

After four weeks of intense work, a group of advocates has submitted forty pages of comments on the P2P systematic evidence review. We published a summary of our comments last week. If you want to read the full document, you can view it in two pieces:

Part One addresses the issues with the Evidence Review’s base assumption that all CFS and ME definitions represent the same disease or set of closely related diseases, and the analysis and conclusions drawn regarding diagnostic methods, accuracy and concordance of definitions, subgroups and diagnostic harms.

Part Two addresses the analysis and conclusions drawn regarding treatment effects and harms; and issues related to applicability, reliability and future research directions.

I was proud to work with the following advocates who join me in making these comments:

  • Mary Dimmock
  • Claudia Goodell, M.S.
  • Denise Lopez-Majano, Speak Up About ME
  • Lori Chapo Kroger, R.N., PANDORA Org CEO and President
  • Pat Fero, MEPD, President, Wisconsin ME & CFS Association, INC.
  • Darlene Fentner
  • Leonard Goodell, Jr.
  • Alan Gurwitt, M.D.
  • Wilhelmina D. Jenkins
  • Joseph Landson, M.S.
  • Margaret Lauritson-Lada
  • Jadwiga Lopez-Majano
  • Mike Munoz, PANDORA Org Board of Directors
  • Matina Nicholson
  • Charmian Proskauer
  • Mary M. Schweitzer, Ph.D.
  • Amy L. Squires, MPA
  • Susan Thomas
  • Erica Verrillo, Author

There is still time for you to submit your own comments. Feel free to draw inspiration from the work we publish here today, or the other posts I’ve published over the last several weeks.

 

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Evidence Review Comments Preview

Posted on October 15, 2014 by Jennie Spotila

This post comes via Mary Dimmock, Claudia Goodell, Denise Lopez-Majano, and myself. You are welcome to publish it on your site with attribution and a link back to this post. You are also welcome to use this (and other material we’ve gathered) as a framework for your own comments on the draft evidence review – due October 20th.

It’s been a challenging few weeks, digesting and analyzing the AHRQ Draft Systematic Evidence Review on Diagnosis and Treatment of ME/CFS.  We continue to be deeply concerned about the many flaws in the review, in terms of both the approach it took and how it applied the study protocol.

Our comments on the Review will reflect our significant concerns about how the Evidence Review was conducted, the diagnostic, subgroup, and harms treatment conclusions drawn by this report, and the risk of undue harm that this report creates for patients with ME. We believe a final version should not be published until these scientific issues are resolved.

Most fundamentally, the Evidence Review is grounded in the flawed assumption that eight CFS and ME definitions all represent the same group of patients that are appropriately studied and treated as a single entity or group of closely related entities. Guided by that assumption, this Evidence Review draws conclusions on subgroups, diagnostics, treatments and harms for all CFS and ME patients based on studies done in any of these eight definitions. In doing so, the Evidence Review disregards its own concerns, as well as the substantial body of evidence that these definitions do not all represent the same disease and that the ME definitions are associated with distinguishing biological pathologies. It is unscientific, illogical and risky to lump disparate patients together without regard to substantive differences in their underlying conditions.

Compounding this flawed assumption are the a priori choices in the Review Protocol that focused on a more narrow set of questions than originally planned and that applied restrictive inclusion and exclusion criteria. As a result, evidence that would have refuted the flawed starting assumption or that was required to accurately answer the questions was never considered. Some examples of how these assumptions and protocol choices negatively impacted this Evidence Review include:

  • Evidence about the significant differences in patient populations and in the unreliability and inaccuracy of some of these definitions was ignored and/or dismissed. This includes: Dr. Leonard Jason’s work undermining the Reeves Empirical definition; a study that shows the instability of the Fukuda definition over time in the same patients; studies demonstrating that Fukuda and Reeves encompass different populations; and differences in inclusion and exclusion criteria, especially regarding PEM and psychological disorders.
  • Diagnostic methods were assessed without first establishing a valid reference standard. Since there is no gold reference standard, each definition was allowed to stand as its own reference standard without demonstrating it was a valid reference.
  • Critical biomarker and cardiopulmonary studies, some of which are in clinical use today, were ignored because they were judged to be intended to address etiology, regardless of the importance of the data. This included most of Dr. Snell’s and Dr. Keller’s work on two day CPET, Dr. Cook’s functional imaging studies, Dr. Gordon Broderick’s systems networking studies, Dr. Klimas’s and Dr. Fletcher’s work on NK cells and immune function, and all of the autonomic tests. None of it was considered.
  • Treatment outcomes associated with all symptoms except fatigue were disregarded, potentially resulting in a slanted view of treatment effectiveness and harm. This decision excluded Dr. Lerner’s antiviral work, as well as entire classes of pain medications, antidepressants, anti-inflammatories, immune modulators, sleep treatments and more. If the treatment study looked at changes in objective measures like cardiac function or viral titers, it was excluded. If the treatment study looked at outcomes for a symptom other than fatigue, it was excluded.
  • Treatment trials that were shorter than 12 weeks were excluded, even if the treatment duration was therapeutically appropriate. The big exclusion here was the rituximab trial; despite following patients for 12 months, it was excluded because administration of rituximab was not continuous for 12 weeks (even though rituximab is not approved for 12 weeks continuous administration in ANY disease). Many other medication trials were also excluded for not meeting the 12 week mark.
  • Counseling and CBT treatment trials were inappropriately pooled without regard for the vast differences in therapeutic intent across these trials. This meant that CBT treatments aimed at correcting false illness beliefs were lumped together with pacing and supportive counseling studies, and treated as equivalent.
  • Conclusions about treatment effects and harms failed to consider what is known about ME and its likely response to the therapies being recommended. This means that the PACE (an Oxford study) results for CBT and GET were not only accepted (despite the many flaws in those data), but were determined to be broadly applicable to people meeting any of the case definitions. Data on the abnormal physiological response to exercise in ME patients were excluded, and so the Review did not conclude that CBT and GET could be harmful to these patients (although it did allow it might be possible).
  • The Evidence Review states that its findings are applicable to all patients meeting any CFS or ME definition, regardless of the case definition used in a particular study.

The issues with this Evidence Review are substantial in number, magnitude and extent. At its root is the assumption that any case definition is as good as the rest, and that studies done on one patient population are applicable to every other patient population, despite the significant and objective differences among these patients. The failure to differentiate between patients with the symptom of subjective unexplained fatigue on the one hand, and objective immunological, neurological and metabolic dysfunction on the other, calls into question the entire Evidence Review and all conclusions made about diagnostic methods, the nature of this disease and its subgroups, the benefits and harms of treatment, and the future directions for research.

As the Evidence Review states, the final version of this report may be used in the development of clinical practice guidelines or as a basis for reimbursement and coverage policies. It will also be used in the P2P Workshop and in driving NIH’s research strategy. Given the likelihood of those uses and the Evidence Review’s claim of broad applicability to all CFS and ME patients, the flaws within this report create an undue risk of significant harm to patients with ME and will likely confound research for years to come. These issues must be addressed before this Evidence Review is issued in its final form.

 

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