The PACE trial should be retracted because it was seriously unethical

Posted on 03/22/2021 by wames

The PACE trial should be retracted, because it was seriously unethical, and the lead investigators continue to deny that, by Dr Neil McFarlane in DrNMblog, 19 March 2021

This was submitted (December 2020) to NICE in response to the new draft ME/CFS guidance of November 2020, which had removed the recommendation for Graded Exercise Therapy (GET), and downgraded CBT from therapeutic to a ‘supportive’ option.

I appear to be the first UK psychiatrist to be openly critical of the PACE trial.

My submission:

The PACE trial was seriously unethical. The senior researchers continue to deny this, despite the clear evidence. Therefore the trial is not only at ‘high risk of bias’, but at significant risk of fraud, and it should be retracted as a trial of treatments…

 

…The PACE trial may be of some historical interest and even future relevance in relation to depression and anxiety in ME/CFS, and on the issue as to whether CFS might validly be considered a separate condition from both ME and depression, as appears to be the view and experience of some patients and some PACE-independent professionals.

The reported rates of anxiety syndromes plus depression (47%) and depression alone (34%) were high. Many people do find CBT helpful as a form of support for those conditions, so it is reasonable for NICE to recommend CBT as a form of support, but a caution should be added about the risk of harm, especially if coercion might encroach. This caution might be reinforced by adopting the term ‘cognitive behavioural support’, or ‘CBS’, in place of ‘CBT’. NICE should also recommend research into other forms of psychosocial support.

The reported rate of ‘post-exertional malaise’ (PEM/PENE) was also high (82-87%), suggesting that its presence or absence cannot be used as the sole criterion for ME/CFS. That is an issue which continues to concern ME/CFS patients and PACE-independent professionals, and therefore justifies further research, especially on the question of whether some people with non-ME/CFS depression have similar PEM. If there is a separate ‘CFS’ entity, then the nature and degree of PEM in that would also be relevant.

Read the full article

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COVID-19 (& ME/CFS?): a methyl-group assault?

Posted on 03/19/2021 by wames

COVID-19: A methyl-group assault? by Andrew McCaddon, Björn Regland in Medical Hypotheses Vol 149, Apr 2021, 110543 [ doi.org/10.1016/j.mehy.2021.110543]

 

Research abstract:

The socio-economic implications of COVID-19 are devastating. Considerable morbidity is attributed to ‘long-COVID’ – an increasingly recognized complication of infection. Its diverse symptoms are reminiscent of vitamin B12 deficiency, a condition in which methylation status is compromised.

We suggest why SARS-CoV-2 infection likely leads to increased methyl-group requirements and other disturbances of one-carbon metabolism. We propose these might explain the varied symptoms of long-COVID. Our suggested mechanism might also apply to similar conditions such as myalgic encephalomyelitis/chronic fatigue syndrome.

The hypothesis is evaluable by detailed determination of vitamin B12 and folate status, including serum formate as well as homocysteine and methylmalonic acid, and correlation with viral and host RNA methylation and symptomatology. If confirmed, methyl-group support [supplementation] should prove beneficial in such individuals.

Conclusion

We suggest that SARS-CoV-2 induces an increased demand for methyl-groups whilst simultaneously impairing their supply due to viral-induced oxidative stress.

The biochemical implications of our hypothesis might explain the diverse symptoms experienced by patients with long-COVID and, if confirmed, suggests possible approaches to treatment.

It would be ironic if the socio-economic devastation of COVID-19, by intensifying world-wide research in a viral pandemic, leads to valuable insights into other conditions such as ME/CFS, as well as providing additional clues to the aetiology of memory disorders and dementia, including Alzheimer’s disease.

Image by mcmurryjulie from Pixabay

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Effects of Post-Exertional Malaise on markers of arterial stiffness in individuals with ME/CFS

Posted on 03/16/2021 by wames

Effects of Post-Exertional Malaise on markers of arterial stiffness in individuals with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, by Joshua Bond, Tessa Nielsen and Lynette Hodges in Int J Environ Res Public Health 2021 Feb 28;18(5):2366 [doi: 10.3390/ijerph18052366]

 

Research abstract:

Background:

Evidence is emerging that individuals with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) may suffer from chronic vascular dysfunction as a result of illness-related oxidative stress and vascular inflammation. The study aimed to examine the impact of maximal-intensity aerobic exercise on vascular function 48 and 72 h into recovery.

Methods:

ME/CFS (n = 11) with gender and age-matched controls (n = 11) were randomly assigned to either a 48 h or 72 h protocol. Each participant had measures of brachial blood pressure, augmentation index (AIx75, standardized to 75 bpm) and carotid-radial pulse wave velocity (crPWV) taken. This was followed by a maximal incremental cycle exercise test. Resting measures were repeated 48 or 72 h later (depending on group allocation).

Results:

No significant differences were found when ME/CFS were directly compared to controls at baseline. During recovery, the 48 h control group experienced a significant 7.2% reduction in AIx75 from baseline measures (p < 0.05), while the matched ME/CFS experienced no change in AIx75. The 72 h ME/CFS group experienced a non-significant increase of 1.4% from baseline measures. The 48 h and 72 h ME/CFS groups both experienced non-significant improvements in crPWV (0.56 ms-1 and 1.55 ms-1, respectively).

Conclusions:

The findings suggest that those with ME/CFS may not experience exercise-induced vasodilation due to chronic vascular damage, which may be a contributor to the onset of post-exertional malaise (PEM).

 

Health Rising: Are stiffened arteries increasing cardiovascular risk in ME/CFS and Fibromyalgia? by Cort Johnson, 6 April 2020

  • No evidence of arterial stiffness was found at baseline in ME/CFS, but the 48 hours after-exercise ME/CFS patients’ arterial stiffness was increased relative to the controls.
  • Exercise had increased arterial elasticity in the healthy controls but not in the people with ME/CFS.
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Hypothesis: mechanisms that prevent recovery in prolonged ICU patients also underlie ME/CFS

Posted on 03/15/2021 by wames

Hypothesis: mechanisms that prevent recovery in prolonged ICU patients also underlie Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), by Dominic Stanculescu,  Lars Larsson and Jonas Bergquist in Frontiers in Medicine (2021) 8(41) [doi: 10.3389/fmed.2021.628029] (This article is part of the research topic: Current Insights into Complex Post-Infection Fatigue Syndromes with Unknown Aetiology: the Case of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome and Beyond)

 

Article abstract:

Here the hypothesis is advanced that maladaptive mechanisms that prevent recovery in some intensive care unit (ICU) patients may also underlie Myalgic encephalomyelitis/ chronic fatigue syndrome (ME/CFS).

Specifically, these mechanisms are: (a) suppression of the pituitary gland’s pulsatile secretion of tropic hormones, and (b) a “vicious circle” between inflammation, oxidative and nitrosative stress (O&NS), and low thyroid hormone function.

This hypothesis should be investigated through collaborative research projects.

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Our evolving understanding of ME/CFS – Post Active Phase of Infection Syndromes (PAPIS)

Posted on 03/12/2021 by wames

Our evolving understanding of ME/CFS, by Kenneth J Friedman, Modra Murovska, Derek FH Pheby, Paweł Zalewski in Medicina Vol 57, #3, p 200, Feb 26, 2021 [https://doi.org/10.3390/medicina57030200] (This article belongs to the Special Issue ME/CFS: Causes, Clinical Features and Diagnosis)

 

Article abstract:

The potential benefits of the scientific insights gleaned from years of treating ME/CFS for the emerging symptoms of COVID-19, and in particular Longhaul- or Longhauler-COVID-19 are discussed in this opinion article. Longhaul COVID-19 is the current name being given to the long-term sequelae (symptoms lasting beyond 6 weeks) of SARS-CoV-2 infection.

Multiple case definitions for ME/CFS exist, but post-exertional malaise (PEM) is currently emerging as the ‘hallmark’ symptom. The inability to identify a unique trigger of ME/CFS, as well as the inability to identify a specific, diagnostic laboratory test, led many physicians to conclude that the illness was psychosomatic or non-existent. However, recent research in the US and the UK, championed by patient organizations and their use of the internet and social media, suggest underlying pathophysiologies, e.g., oxidative stress and mitochondrial dysfunction.

The similarity and overlap of ME/CFS and Longhaul COVID-19 symptoms suggest to us similar pathological processes. We put forward a unifying hypothesis that explains the precipitating events such as viral triggers and other documented exposures: For their overlap in symptoms, ME/CFS and Longhaul COVID-19 should be described as Post Active Phase of Infection Syndromes (PAPIS).

We further propose that the underlying biochemical pathways and pathophysiological processes of similar symptoms are similar regardless of the initiating trigger. Exploration of the biochemical pathways and pathophysiological processes should yield effective therapies for these conditions and others that may exhibit these symptoms. ME/CFS patients have suffered far too long.

Longhaul COVD-19 patients should not be subject to a similar fate. We caution that failure to meet the now combined challenges of ME/CFS and Longhaul COVID-19 will impose serious socioeconomic as well as clinical consequences for patients, the families of patients, and society as a whole.

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Cardiff University student ME/CFS Project – can you help?

Posted on 03/12/2021 by wames

Cardiff University Project – GP info leaflet

 

My name is Imogen Young and I’m a 3rd year medical student at Cardiff University.

I’m taking part in a 6-week project to produce an informative leaflet for GPs about diagnosis and management of Myalgic Encephalitis/Chronic Fatigue Syndrome (ME/CFS).

I’m looking to speak to a handful of volunteers with ME/CFS in a telephone interview about your experiences in primary care. I also want to gain an insight into the experience of living with ME/CFS.

All volunteers should be over 18 years old and be well enough to speak for 15-30 minutes without deterioration to your health.

Please contact me on Youngi1@Cardiff.ac.uk if you wish to be involved.

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Perceptions of European ME/CFS experts concerning knowledge & understanding of ME/CFS among primary care physicians in Europe

Posted on 03/10/2021 by wames

Perceptions of European ME/CFS experts concerning knowledge and understanding of ME/CFS among primary care physicians in Europe: a report from the European ME/CFS Research Network (EUROMENE), by John Cullinan, Derek F H Pheby, Diana Araja, Uldis Berkis, Elenka Brenna, Jean-Dominique de Korwin, Lara Gitto, Dyfrig A Hughes, Rachael M Hunter, Dominic Trepel, Xia Wang-Steverding in Medicina (Kaunas) Vol 57, #3, p 208, Feb 26, 2021 [doi.org/10.3390/medicina57030208]

 

Research abstract:

Background and Objectives

We have conducted a survey of academic and clinical experts who are participants in the European ME/CFS Research Network (EUROMENE) to elicit perceptions of general practitioner (GP) knowledge and understanding of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and suggestions as to how this could be improved.

 

Materials and Methods

A questionnaire was sent to all national representatives and members of the EUROMENE Core Group and Management Committee. Survey responses were collated and then summarized based on the numbers and percentages of respondents selecting each response option, while weighted average responses were calculated for questions with numerical value response options. Free text responses were analysed using thematic analysis.

Results

Overall there were 23 responses to the survey from participants across 19 different European countries, with a 95% country-level response rate.

Serious concerns were expressed about GPs’ knowledge and understanding of ME/CFS, and, it was felt, about 60% of patients with ME/CFS went undiagnosed as a result. The vast majority of GPs were perceived to lack confidence in either diagnosing or managing the condition. Disbelief, and misleading illness attributions, were perceived to be widespread, and the unavailability of specialist centres to which GPs could refer patients and seek advice and support was frequently commented upon.

There was widespread support for more training on ME/CFS at both undergraduate and postgraduate levels.

Conclusion

The results of this survey are consistent with the existing scientific literature. ME/CFS experts report that lack of knowledge and understanding of ME/CFS among GPs is a major cause of missed and delayed diagnoses, which renders problematic attempts to determine the incidence and prevalence of the disease, and to measure its economic impact. It also contributes to the burden of disease through mismanagement in its early stages.

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Managing COVID-19 post viral fatigue syndrome

Posted on 03/07/2021 by wames

Managing COVID-19 post viral fatigue syndrome, by Charles W Lapp and Joseph F John  in Fatigue: Biomedicine, Health & Behavior, Feb 22, 2021

 

Article abstract:

In online surveys, over 50% of persons who contract COVD-19 experience symptoms lasting longer than 90 days [Pelanti S, Grassi E, Markris N, et al. J Psych Res. 2020. doi:10.1016/j.jpsychires.2020.08.008]

Despite an estimated 3 million Americans being affected by COVID post-viral fatigue, there has been little discussion about the care of these patients, most of whom report feeling unsupported or dismissed by their providers [Amitay O, Komaroff AL. The Guardian, 20 Aug 2020].

This article points out the similarity between this post-viral fatigue syndrome and Chronic Fatigue Syndrome (ME/CFS) or Systemic Exertion Intolerance Disease (SEID), and offers evidence-based suggestions for management.

Recommendations for management

One year has elapsed with the COVID-19 pandemic, and it appears that this novel virus is capable of causing a syndrome similar to ME/CFS, as many other infections have done in the past. There is currently no Standard of Care for the management of such Long Haulers, so our recommendations are based on past experiences with SARS, expert opinion, our experience with ME/CFS, as well as expanding knowledge of COVID-19 illness. Here, we offer a sequence for diagnosis and treatment based primarily on our experience treating ME/CFS.

First, a rigorous history and physical examination should commence care. Second, routine testing should be performed to establish a baseline and to rule out sequelae of the disease that might produce chronic fatigue (see Table 2). Third, patients should be encouraged to rest frequently and aggressively and to set limits on daily activities so as to avoid exacerbations of their symptoms and post-exertional malaise. Overexertion leads to a prolonged exacerbation of symptoms (known as ‘post-exertional malaise’ or PEM) in persons with ME/CFS, and empirically we know that repeated PEM perpetuates or worsens the illness. Therefore, it is imperative that patients be advised to limit activity and balance activity with adequate rest in order to avoid PEM. Finally, clinicians can address the major issues of sleep disruption, pain, orthostatic symptoms, headache, and other co-morbidities so common in ME/CFS. These symptoms can be managed in the usual manner or referral to specialists.

Sleep disruption frequently responds to simple measures such as melatonin, over-the-counter antihistamines (such as diphenhydramine or doxylamine), or low doses of amitriptyline, nortriptyline, or trazodone. Primary sleep disorders are common in ME/CFS, so highly consider specialist referral and polysomnography if sleep remains problematic.

Pain is very common in ME/CFS but is frequently managed with physical therapies (hot or cold packs, Epsom soaks, massage, topical creams or liniments). In the past few years, low dose naltrexone (0.1–5 mg daily) has proved to be useful for myalgic pain. For more severe pain non-narcotic pain medications such as pregabalin, duloxetine or milnacipran are recommended. Opiates – if considered appropriate – might best be prescribed by a pain specialist.

Orthostatic symptoms such as lightheadedness, dizziness, upright intolerance, orthostatic hypotension or tachycardia, and even neurally mediated hypotension are common in ME/CFS. Management begins with volume expansion (drinking at least 64 ounces of water or non-caffeinated beverage daily and ingesting extra salt – if not hypertensive). Tachycardia may require a beta-blocker for symptomatic relief. If orthostasis is not improved by volume expansion (including parenteral fluids) consider consultation by cardiology.

Treating fatigue requires novel approaches as fatigue may respond to agents that clinicians may not regularly employ in their routine practices. This constellation may involve caffeinated drinks, low dose naltrexone, the use of stimulants including modafinil and methylphenidate, and other agents including antivirals. Other modalities including a wide variety of non-prescription supplements may help optimize the patient’s health. The following supplements are recommended based on available evidence:

  • Vitamin C may shorten or lessen the symptoms of the common cold (frequently caused by coronaviruses), and benefit the immune system. Studies are underway looking at the potential of Vitamin C in more severe cases of COVID-19. A dose of 500 mg per day is generally safe, with a maximum of 2000 mg daily.

  • Vitamin D3: Research has shown that countries whose population had lower levels of 25-OH Vitamin D had a higher incidence of COVID, and individuals with higher levels of 25-OH Vitamin D at illness onset have a milder course and lower rate of ICU admissions. Consider at least 1000–2000 iu daily to start. Because Vitamin D is fat soluble, individuals with a high body mass will likely require more.

  • Echinacea increases NK Cell Activity thereby supporting, if needed, the body’s antiviral system. It has been used to prevent upper respiratory tract infections. The usual dose is 300 mg daily, and drug holidays are recommended to avoid stimulating autoantibodies. Echinacea is contraindicated in RA, lupus erythematosus, multiple sclerosis, and other conditions associated with autoantibodies.

  • B12 and folate. These serum levels tend to be low in persons with ME/CFS, suggesting that supplementation might be beneficial. Methyl-cobalamin is taken as 1000 mcg daily along with 400–1000 mcg daily of methyl-folate.

  • CoQ10 also tends to be low in persons with ME/CFS. This is the most ubiquitous cofactor in the human body and supplementation with 100–200 mg daily might benefit metabolism.

  • Turmeric (curcumin) is a spice used in curry and mustard. However, it possesses potent antioxidant activity and reduces inflammation. It is particularly useful for mild muscle and joint aching, but is contraindicated in pregnancy due to its ability to cause uterine contractions. The usual dose is 500 mg twice daily.

If for no other reason, supplementation may enhance one’s innate and adaptive immune response, suppress inflammation, and reduce oxidative stress. The literature suggests the use of Vitamins A, D, C, B12, B6 and folate; micronutrients zinc, iron, selenium, copper; and omega-3 fatty acids as essential. In COVID-19, Vitamin D, selenium, and iron seem to be most important.

Although their effect on COVID-19 is controversial, current guidelines recommend continuation of therapy with ACE inhibitors (ACEI) or angiotension receptor blockers (ARBs).

See the full article for:

Overview & testing of COVD-19

Post-viral & post-COVID fatigue

Post-Viral Fatigue Syndrome (PVFS) versus Chronic Fatigue Syndrome (ME/CFS)

Table 1. Criteria for the Clinical Diagnosis of ME/CFS

Table 2. Clinical and Laboratory Testing of COVID-19 Long Haulers

Online resources for long haulers and ME/CFS

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Recursive ensemble feature selection provides a robust mRNA expression signature for ME/CFS

Posted on 03/04/2021 by wames

Recursive ensemble feature selection provides a robust mRNA expression signature for myalgic encephalomyelitis/chronic fatigue syndrome, by Paula I Metselaar, Lucero Mendoza-Maldonado, Andrew Yung Fong Li Yim, Ilias Abarkan, Peter Henneman, Anje A Te Velde, Alexander Schönhuth, Jos A Bosch, Aletta D Kraneveld, Alejandro Lopez-Rincon in Sci Rep. 2021 Feb 25;11(1):4541 [doi: 10.1038/s41598-021-83660-9]

 

Research abstract:

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic disorder characterized by disabling fatigue. Several studies have sought to identify diagnostic biomarkers, with varying results.

Representation of a DNA molecule that is methylated. The two white spheres represent methyl groups. They are bound to two cytosine nucleotide molecules that make up the DNA sequence.

Here, we innovate this process by combining both mRNA expression and DNA methylation data. We performed recursive ensemble feature selection (REFS) on publicly available mRNA expression data in peripheral blood mononuclear cells (PBMCs) of 93 ME/CFS patients and 25 healthy controls, and found a signature of 23 genes capable of distinguishing cases and controls. REFS highly outperformed other methods, with an AUC of 0.92.

We validated the results on a different platform (AUC of 0.95) and in DNA methylation data obtained from four public studies on ME/CFS (99 patients and 50 controls), identifying 48 gene-associated CpGs that predicted disease status as well (AUC of 0.97). Finally, ten of the 23 genes could be interpreted in the context of the derailed immune system of ME/CFS.

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A systematic review of nutraceutical interventions for mitochondrial dysfunctions in ME/CFS

Posted on 03/03/2021 by wames

A systematic review of nutraceutical interventions for mitochondrial dysfunctions in myalgic encephalomyelitis/chronic fatigue syndrome, by  in Journal of Translational Medicine vol 19, no.: 81 (2021)

 

Review abstract:

Background
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a debilitating illness, characterised by persistent fatigue that is unrelieved by rest, in combination with a range of other disabling symptoms. There is no diagnostic test nor targeted treatment available for this illness. The pathomechanism also remains unclear. Mitochondrial dysfunctions have been considered a possible underlying pathology based on reported differences including structural and functional changes in ME/CFS patients compared to healthy controls. Due to the potential role that mitochondria may play in ME/CFS, mitochondrial-targeting nutraceutical interventions have been used to potentially assist in improving patient outcomes such as fatigue. The aim of this systematic review is to appraise literature assessing these nutraceuticals as a possible intervention for treating ME/CFS.

Methods
A systematic search of Pubmed, Embase, Medline (EBSCO host) and Web of Science (via Clarivate Analytics) for journal articles published between January 1995 and 10th November 2020 was conducted. Articles assessing nutraceutical interventions and ME/CFS patient outcomes were retrieved. Using specific inclusion and exclusion criteria, the list of articles was further refined. Quality was measured using the Rosendal scale.

Results
Nine intervention studies were included in this review. The studies investigated patient symptom severity changes such as altered fatigue levels in response to mitochondrial-targeting nutraceuticals. Improvements in fatigue levels were observed in six of the nine studies. Secondary outcomes assessed include biochemical, psychological, and quality of life parameters.

Conclusion
There is insufficient evidence on the effectiveness of mitochondria- targeting nutraceuticals in ME/CFS patients. Future well-designed studies are required to elucidate both the involvement of mitochondria in the pathomechanism of ME/CFS and the effect of mitochondrial-modifying agents on illness severity.

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