ME outbreaks can be modelled as an infectious disease: a mathematical reconsideration of the Royal Free Epidemic of 1955

Myalgic Encephalomyelitis (ME) outbreaks can be modelled as an infectious disease: a mathematical reconsideration of the Royal Free Epidemic of 1955, by FG Waters, GJ McDonald, S Banks, RA Waters in Fatigue: Biomedicine, Health & Behavior, 22 July 2020 [doi.org/10.1080/21641846.2020.1793058]

 

Research abstract: 

In 1970, two clinicians, McEvedy and Beard

[McEvedy CP, Beard AW (1970) Royal Free Epidemic of 1955: A Reconsideration The British Medical Journal 1: No. 5687: 7-11]

Royal Free Hospital former site

re-analysed some of the case notes, and hypothesised that the Royal Free outbreak was epidemic hysteria. This hypothesis was the beginning of an entrenched belief that the disease at the Royal Free, and similar cluster outbreaks, were psychosomatic. This was to have a profound effect on the interpretation of the same illness for nearly 50 years as a presumptive psychosomatic, an interpretation that has lasted nearly 50 years.

Methods
The 1927 Susceptible Infected Recovered (SIR) mathematical model

[Kermack WO, McKendrick AG. Contribution to the mathematical theory of epidemics. Proc Royal Soc London. 1927;772:701-721]

for the transmission of disease has been used to examine the published admission data from the Royal Free Hospital for the purpose of finding out if the disease had the characteristics of a contagious disease. Similar cluster outbreaks have also been modelled to assess whether they have similar characteristics to the Royal Free outbreak.

Results
Using the 1927 Susceptible Infected Recovered (SIR) model

[Kermack WO, McKendrick AG. Contribution to the mathematical theory of epidemics. Proc Royal Soc London. 1927;772:701-721]

for the transmission of disease, we show that the epidemic of a disease of an unknown aetiology at the Royal Free Hospital in 1955, and other similar twentieth-century outbreaks, have the characteristics of a communicable disease. The disease causing the Royal Free outbreak was given the name ‘Benign Myalgic Encephalomyelitis’ by Acheson

[A new clinical entity? Lancet. 1956;1:789-790]

in 1956, now identified as ME.

Conclusions
By showing that the Royal Free and other ME attributed outbreaks fit the SIR disease model, we demonstrate that the McEvedy and Beard hysteria hypothesis is mathematically incorrect. The ensuing management of the treatment of ME/CFS-like conditions evolving from that, now mathematically improbable belief may need to be re-evaluated.

4. Conclusions

By using the Susceptible Infected Recovered (SIR) model for the transmission of disease
and comparing actual and predicted admission data we show:

  • The Royal Free cluster outbreak has the mathematical attributes of a contagious
    disease.
  • The cluster outbreaks in Cumbria and Great Ormond Street appear to have the attribute of contagious diseases with similar infection indices (Beta) as the Royal Free.
  • Furthermore, attempting to model a known hysteria outbreak in Kombolcha yielded no viable solution, and the limited results obtained in no way matched the results from modelling the ME cluster outbreaks.

Thus this work mathematically disproves the McEvedy–Beard hypothesis that the cluster outbreak at the Royal Free was due to mass hysteria.

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I have questions for God about why this happened to me

Leeds Church Institute Arts/Theology Bursary blog post: …but maybe I don’t,
by Dr Charlotte Naylor Davis, 22 July 2020

 

Charlotte is a biblical scholar who asks a lot of questions and mainly writes about how the Bible has been used and interpreted over history. ‘I have published on heavy metal and the Bible, and feminist critical thinking, and sci fi. I am usually found asking the question “how did we end up thinking the bible said that?”’ She is currently working with a photographer on an art/theology project for the Leeds Church Institute.

My life took a turn ten years ago.

I did an MA in Biblical Studies and towards the end I got ill. No surprise really, as I had worked for churches doing ministry whilst doing a 2 year part time MA in one year full time. When I came to look back on that year with a doctor later we would realise that I didn’t have more that one day off in a row for over six months. But, I was young and had always worked long hours because I have always picked jobs I loved. I was 30. I never got better from that illness.

At first we thought I was merely burnt out. I was diagnosed with depression because I was sad and tired all the time. I spent the year working an admin job so that I could write my PhD proposal in my spare time and my mood lifted. But I was still exhausted. I had pains in my arms and frequent headaches. I had always had awful menstrual issues but now these resulted in me sleeping for often 18 hours straight once the cramps had gone, unable to think or do anything. But most telling that something was wrong was that I started to lose my words. Nouns started to elude me if I was tired. My husband at the time became a master of lateral thinking because I could often only describe the function of something: can you get my bag, its in…that place where we make the food?

Nouns started to elude me if I was tired.

When we moved to Brighton I would go for walks in the downs. I loved walking alone but found myself unable to get up Devil’s Dyke without constant breaks. I had thrown myself into exercise as this was the remedy for depression. Go outside! Fresh air! But the more I did this the worse it got. After a year, two episodes of fainting at the gym and the constant feeling of weakness we were worried something was wrong with my heart and I bullied my doctor into tests. My mood was fine, I was in a loving home doing the PhD I dreamt of, two cats. I was not depressed. I was sick.

I eventually got a diagnosis of CFS/ME.

Chronic Fatigue Syndrome/ Myalgic Encephalomyelitis.

It was nice to know someone didn’t think I was making it up. It was frustrating because there is neither a cure nor any real treatment. What is wrong with me is a multi-systemic dysfunction which may be neurological though they don’t give you tests. ME is a debilitating illness which needs more study and I can’t explain it fully here so please do go to the ME Association website and find out more. You see for years it has been treated as a mental illness not a physical one. The problem with this being that you cannot, no matter what CBT you get good at, or positive thoughts you have, think your way out of bed if your legs don’t work. And some days they don’t.

Why am I telling you all this?

Well, my ME has irreparably damaged my life and I’m still not ok with it. I have questions for God about why this happened and how I’m meant to deal with it that are unresolved. And that tension I said I loved so much (see previous blog post)….well, it hurts. It manifests as a grief that I can barely express and I don’t like it.

I realised last year that I have been ill for over 10 years. When I got sick no one talked to me about how this would affect my psyche. They talked about physical issues but no one offered me counselling for what I was losing or would miss out on. A 30 year old who had pushed herself her whole life was now forced by her own body to stop. I was not prepared for what I would lose. The rhetoric of illness I had grown up with was one of ‘fighting’. We treat illness as a battle to be won. So I fought. I refused to give in to this thing. I kept going. I ‘managed’ it by giving over my spare time to rest but carrying on working.

The rhetoric of illness I had grown up with was one of ‘fighting’. We treat illness as a battle to be won.

But if illness is a battle then I lost. I am losing. And I wasn’t prepared for that outcome. I wasn’t prepared for the fact that I would get ill and never get better. And because I was taught to think of it as a battle, then every time I gave in, I failed. So I made myself more and more ill.

Better theologians that me have written about disability. The rhetoric of the battle to be won is incredibly damaging to people with chronic illness. We will not physically win this. Maybe we will mentally win…but honestly when the main symptom of your illness is fatigue, deep, debilitating fatigue, most of the time you haven’t the energy to mentally win at anything.

When I finally accepted that I was ill in a way that was disabling, I had to put down many things I loved. Energy for tasks is a 1:1 swap for me so taking a shower is as tiring as seeing a friend; doing my marking is as tiring a going to the pub. I have to make direct choices before a day starts about where I will put my energy.

I have to make direct choices before a day starts about where I will put my energy.

Going to church became impossible. To get up, dressed, presentable and out of the house in the morning was so tiring, but being in the noise and having to concentrate was even more energy. I was always working on Monday so Sunday had to be a day of rest like I had never done. But that meant a chunk of my ministry – teaching young people – was gone. Part of my identity, the way I expressed my faith and service to God – gone.

People would say I was still useful to God because I could still pray…but let me tell you a secret about your friends with exhaustion and fatigue: sometimes we can’t even do that. You see when I get fatigued I can’t string a sentence together. That noun problem I told you about earlier, it’s got worse. I often say words in the wrong order, I don’t remember names, I barely can articulate my immediate need. So coming from a charismatic background I felt utterly lost in my faith practice. All the things I valued were being taken away.

I have lost so much to this illness. And I battled with it for so long that I didn’t face that grief until last year when I realised my 30s had gone by. People were sharing 10 year photos on facebook and nearly everyone had something good to share, and I suddenly reviewed my 10 years and was faced with 30 year old Charlotte’s abilities vs 40 year old Charlottes disability.

I felt utterly lost in my faith practice. All the things I valued were being taken away.

I’d got a PhD in that time, so you’d think it wouldn’t matter. But the amount I can accomplish in a day is down to about 4 really good hours. (by the way, that makes my ME ‘moderate’, that’s how severe this illness can be). I was faced with all the things I hadn’t achieved, and had put to one side. The stark contrast laid out before me of the friend, sister, lover I had been vs the one that I was now caused me considerable grief.

It still does.

And I am both angry and thankful to God about where I am. I don’t understand my illness. I know it could be worse. But not facing the anger and sadness and only being able to talk about what I’m grateful for has also been damaging. Because I had never felt that I was allowed to hold that tension. I have always felt that I am to be grateful because I’m not as ill as I could be, despite the fact that this illness robs me of my one great gift – language and self-expression – I am always ‘meant’ to be able to turn it around to hope. I hate seeing the tension in people’s faces when I tell them how deeply painful this illness is on physical, spiritual and emotional levels. So I resolve it. I do not love that tension.

But not facing the anger and sadness and only being able to talk about what I’m grateful for has also been damaging.

In my darkest moments I question God because I got ill by following what I believed, and others believed, I was called to do. I undertook those jobs with prayer and discernment – why then did they lead to this?

Now, I know I could have managed my life better. I know that the cause of my ME is not so straightforward. I know that theologies of illness and healing are also not so simple as ‘if I had faith I would be made well’…but my darkest moments I wonder what I did to deserve this. I wonder why I am not healed when my disability has caused me to lay down exactly what I was sure was my calling from God. I question why God would make such frail bodies? What did I do that caused this?

my illness makes me scared and my question comes not from my intellect but from my fear.

You see, questioning is a pastoral issue.

Because I don’t really think that I caused this illness, my illness makes me scared and my question comes not from my intellect but from my fear.

I don’t really want a discussion about healing – I have read and seen enough to know that my body is valuable and wonderful as it is. But my question comes from my grief and my difficulty getting used to this new body and getting used to limitations.

When I ask “what is the point of me if I can’t even pray?” I am not actually asking for an answer, I’m searching for that parental embrace that tells you that your very existence is a joy.

So I have to be honest with you I do not love these questions or these tensions. I wish they did not exist. They pop up when I don’t get a job because of gaps in my CV that are due to the illness, and I get angry. They rear their heads when I forget to call someone and have to make an excuse, or I can’t express a simple request without getting frustrated at my partner and I get sad. They come from wounds which open every time I have to turn down work, or tell a friend I can’t be at something to support them, or tell my family I can’t do Christmas, or my partner that I can’t listen to them today because noise hurts me. They come from a place that some days is too difficult to articulate.

And those questions still hurt, even though I know that God is big enough that I don’t have to choose between frustration and thankfulness. They still just hurt.

I believe God is in the tension even when it hurts. I believe God is in the darkness holding our hand as we get used to new realities. I believe God is the light in that darkness when we feel safe enough to see it again.

As I compile the questions that people have been sending in to Phill (for the House of Questions project) I am mindful of the fact that questioning is a pastoral issue. We want to give something that helps people questions and hold tension and maybe even enjoy it. But I am not taking them lightly. I shall not tell you that you just need to enjoy the tension. I know that some of these things come from your deepest parts and I will be gentle.

because I love questions….but also, maybe I don’t.

Read more from Charlotte’s blog

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Plasma proteomic profiling suggests an association between antigen driven clonal B cell expansion & ME/CFS

Plasma proteomic profiling suggests an association between antigen driven clonal B cell expansion and ME/CFS, by Milica Milivojevic, Xiaoyu Che, Lucinda Bateman, Aaron Cheng, Benjamin A Garcia, Mady Hornig, Manuel Huber, Nancy G Klimas,Bohyun Lee, Hyoungjoo Lee, Susan Levine, Jose G Montoya, Daniel L Peterson, Anthony L Komaroff, W Ian Lipkin in PLoS One. 2020 Jul 21;15(7):e0236148 [doi:10.1371/journal.pone.0236148]

 

Research abstract:

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is an unexplained chronic, debilitating illness characterized by fatigue, sleep disturbances, cognitive dysfunction, orthostatic intolerance and gastrointestinal problems. Using ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS), we analyzed the plasma proteomes of 39 ME/CFS patients and 41 healthy controls.

Logistic regression models, with both linear and quadratic terms of the protein levels as independent variables, revealed a significant association between ME/CFS and the immunoglobulin heavy variable (IGHV) region 3-23/30. Stratifying the ME/CFS group based on self-reported irritable bowel syndrome (sr-IBS) status revealed a significant quadratic effect of immunoglobulin lambda constant region 7 on its association with ME/CFS with sr-IBS whilst IGHV3-23/30 and immunoglobulin kappa variable region 3-11 were significantly associated with ME/CFS without sr-IBS.

In addition, we were able to predict ME/CFS status with a high degree of accuracy (AUC = 0.774-0.838) using a panel of proteins selected by 3 different machine learning algorithms: Lasso, Random Forests, and XGBoost. These algorithms also identified proteomic profiles that predicted the status of ME/CFS patients with sr-IBS (AUC = 0.806-0.846) and ME/CFS without sr-IBS (AUC = 0.754-0.780). Our findings are consistent with a significant association of ME/CFS with immune dysregulation and highlight the potential use of the plasma proteome as a source of biomarkers for disease.

 

Excerpt from Discussion

Whilst our exploratory study has identified a plasma protein biosignature using machine-learning algorithms that can predict ME/CFS status adequately, the clinical utility of these results remains to be shown. Validation of the panel of proteins in larger cohorts is needed to determine whether it would make a reliable biomarker. In addition, the specificity of the biosignature would need to be assessed to see if it could successfully distinguish ME/CFS cases, as well as ME/CFS cases with or without sr-IBS, from those with other fatiguing illnesses such as fibromyalgia and Gulf War Illness. Disease-specific specific biomarkers could provide an objective measure to aid in diagnosis of this heterogeneous disease. Previous proteomic studies in cerebrospinal fluid and saliva have identified protein signatures with predictive accuracies comparable to ours [11, 14], however, none have led to the development clinical biomarkers. In fact, no molecular biomarkers have been validated for ME/CFS diagnosis or prognosis [4], highlighting the challenges associated with this complex disease. Our work, whilst exploratory in nature, shows that the plasma proteome is a viable and untapped source of potential biomarkers in ME/CFS, and can provide insight into disease pathophysiology. In addition, we support previous results that ME/CFS patients with sr-IBS may constitute a subgroup with a distinct molecular profile [9, 26] and that considering subtypes of ME/CFS can lead to greater predictive accuracy in biomarker studies.

Our study is limited by small sample size, and the robustness of our findings needs to be verified in larger cohorts. Additionally, IBS status determination and stratification could be improved by an independent diagnosis at the time of participant recruitment. Nonetheless, our results comport with other work in ME/CFS that has found evidence in ME/CFS of immune dysregulation, B cell dysfunction, chronic inflammation, oxidative stress, and autoimmunity.

Comment:

A Proteomics Study from the Center: Searching for the Criminal, by Dr Anthony Komaroff, Jul 28 2020

What did the latest study from the Center show? Basically, two things:

  • There appears to be a distinctive “signature” of a small group of proteins that distinguishes people with ME/CFS from healthy people;
  • The proteins involved in that “signature” are primarily involved in the immune response—particularly the response of immune cells called B cells—to infections, and the response seen in autoimmune diseases.
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Coronavirus: why are some people experiencing long-term fatigue?

The Conversation blog post: Coronavirus: why are some people experiencing long-term fatigue?, by Prof Frances Williams, 16 July 2020

 

People who have been seriously unwell and treated on intensive care units can expect to take some months to recover fully, regardless of their ailment. However, with COVID-19, evidence is mounting that some people who have had relatively mild symptoms at home may also have a prolonged illness. Overwhelming fatigue, palpitations, muscle aches, pins and needles and many more symptoms are being reported as after-effects of the virus. Around 10% of the 3.9 million people contributing to the COVID Symptom Study app have effects lasting more than four weeks.

Chronic fatigue – classified as fatigue lasting more than six weeks – is recognised in many different clinical settings, from cancer treatment to inflammatory arthritis. It can be disabling. If 1% of the 290,000 or so people who have had COVID-19 in the UK remain under the weather at three months, this will mean thousands of people are unable to return to work. They will probably have complex needs that the NHS is ill-prepared to address at present.

COVID-19 is not the only cause of chronic fatigue. Prolonged fatigue is well recognised after other viral infections such as the Epstein-Barr virus, which causes infectious mononucleosis (also known as glandular fever). Post-viral fatigue was also seen in a quarter of those infected with the original Sars virus in Hong Kong in 2003.

When it comes to treating chronic fatigue, the emphasis previously has been on effective treatment of the underlying disease, in the belief that this would diminish the fatigue. However, for most viral infections there is no specific treatment, and because COVID-19 is so new, we don’t yet know how to manage post-COVID fatigue.

What might be causing post-COVID fatigue?

Although we know that lasting fatigue can sometimes follow other viral infections, detailed mechanistic insight is, for the most part, lacking. An ongoing viral infection in lung, brain, fat or other tissue may be one mechanism. A prolonged and inappropriate immune response after the infection has been cleared might be another.

However, a previous study has given us some insight. When a chemical called interferon-alpha was given to people as a treatment for hepatitis C, it generated a flu-like illness in many patients and post-viral fatigue in a few. Researchers have studied this “artificial infection response” as a model of chronic fatigue. They found that baseline levels of two molecules in the body that promote inflammation – interleukin-6 and interleukin-10 – predicted people’s subsequent development of chronic fatigue.

Of particular interest, these same pro-inflammatory molecules are seen in the “cytokine storm” of severely ill COVID-19 patients. This suggests there might be a pattern of immune system activation during the viral infection that is relevant to ongoing symptoms. Further support for interleukin-6 playing some sort of role comes from the successful use of tocilizumab – a treatment that lessens the impact of interleukin-6 and reduces inflammation – to treat severe COVID-19.

Read the full article for info about Covid-19 research at Kings College, London and the need to pace when managing chronic fatigue. Prof Williams recommends Dr Muirhead’s ME/CFS course for clinicians at StudyPRN.

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‘I need to start listening to what my body is telling me’: Does mindfulness-based cognitive therapy help people with CFS?

‘I need to start listening to what my body is telling me.’: Does mindfulness-based cognitive therapy help people with Chronic Fatigue Syndrome? by Bridie O’Dowd & Gemma M Griffith in Human arenas 2020, July 16 [https://doi.org/10.1007/s42087-020-00123-9]

 

Research abstract:

Mindfulness-Based Cognitive Therapy (MBCT) was lightly adapted for participants diagnosed with chronic fatigue syndrome (CFS). The aim of the study was to explore participants’ experiences of the MBCT course, with a particular focus on how they applied MBCT to living with and coping with the symptoms of CFS.

Nine participants with CFS who completed the MBCT course were interviewed using semi-structured interview methods. Inductive thematic analysis, a methodology designed to generate themes from the ‘bottom up,’ was used.

Four superordinate themes were generated from the data: (1) awareness of unhelpful
behavioral patterns associated with CFS, (2) benefits of group solidarity, (3) use of mindfulness tools to facilitate shifts in behavioral patterns, and (4) a sense of change and agency.

Participants became aware of three specific transformative changes that contributed
to a more skillful way of living with CFS: development of acceptance, improved self-care and self-compassion, and reduction in heightened stress response. MBCT appears to enable people with CFS to actively work with their symptoms, and make transformative changes in their behavioral patterns, resulting in benefits to well-being.

 

Excerpts from Discussion:

During the course, participants described how they became aware of specific vulnerabilities that are particular to CFS, and with the support of the group and specific mindfulness tools, reported a change in habit patterns which maintain and perpetuate CFS, such as perfectionism, being driven, people-pleasing, and tendency to catastrophize. There were three very specific transformative changes that occurred as a result of the MBCT course, which were supported across the four superordinate themes. These were the development of acceptance, a cultivation of self-care, and a reduction in heightened stress reaction.

Development of Acceptance
Given the chronic, unpredictable nature of CFS and the lack of curative treatment, cultivating a stance of acceptance of “what is,” shifted the participants’ agenda from a goal of “getting rid” of their condition to working skillfully with it. Crane (2008) describes the goal-driven “doing” mode as being cognitively focused and future orientated. This creates a tendency to discrepancy monitor, that is, monitoring the mismatch between where one actually is and the goal of where one wants to be (Bishop et al. 2004; Segal et al. 2013). The participants developed awareness that this striving to close the gap of how they found themselves and how they wished themselves to be, often demanded large amounts of draining energy.

The shift to acceptance, as a valid mode of coping with CFS, was enhanced by the mutual, supportive learning environment of the class. For some participants, acceptance involved acknowledging the fundamental truth of their current disability. For others, it was a recognition of the impossibility of meeting previous high standards and a welcome letting go of the exhausting maintenance of habit patterns. After the course, participants recognized that these patterns such as perfectionism, people pleasing, and feeling guilty were not only counterproductive but also potentially instrumental in the etiology of their condition (Hambrook et al. 2011; Luyten et al. 2011; Van Houdenhove and Luyten 2008).

Cultivation of Self-Care
The extant research which explores MBPs for CFS populations reported significant shifts in self-reported measures of anxiety, somatization, and unhelpful cognitions and behaviors (Rimes and Wingrove 2013; Sampalli et al. 2009; Surawy et al. 2005). However only the latter of these studies measured and reported improvement in self-compassion scores (Neff 2003). This study showed that increased self-care and self-compassion were fundamental to the shift participants experienced in managing their CFS.

This shift to enhanced self-kindness appeared to arise from a willingness to step out of the driven, energy-draining personality traits of perfectionism, high standards, conscientious, driven working style, and a strong susceptibility to self-criticism (Hambrook et al. 2011; Luyten et al. 2011). The mechanisms by which the mindfulness training enabled this shift appeared to be threefold. First, there was an increased awareness and an intention to “listen” to symptoms rather than ignore them. This led to a more gentle, kindly, and forgiving attitude towards their bodies experiencing fatigue and pain.

Second, the participants developed metacognitive awareness (Bishop et al. 2004; Teasdale 1999), allowing them to observe their thought processes more clearly. This allowed them to recognize the critical, driven nature of their self-narrative and enabled them to create a kinder less judgmental inner-dialog. Third, the kindness and care developed within the group acted as a medium in which a “permission to self-care” was cultivated. This permission frequently translated into a license to rest, previously un-granted because striving and pushing was so ingrained and prevalent. This shift frequently resulted in protection and preservation and replenishing of limited energy.

Reduction in Stress Reaction
As the course progressed, many participants became aware of an exaggerated stress response, felt physically in the body as pain and fatigue, emotionally as anxiety, and cognitively as fast, racing thoughts. This awareness led participants to actively apply mindfulness to reduce their stress response. First, they found the breath gave them a sense of grounding, calming, stepping back, and providing rest from stressful experiences and reactions. Second, they found everyday mindfulness allowed them to shift attention from catastrophizing thoughts, which would inevitably generate a high stress response onto the more neutral actuality of what they were doing in that moment. Third, they developed a self-soothing inner-dialog that encouraged them to move attention to the breath, remember that thoughts are not facts, and recognize that there may be a habitually exaggerated response going on that they could disengage from. As a result, many of the group reported a reduction in pain and fatigue.

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Cognitive function declines following orthostatic stress in adults with ME/CFS

Cognitive Function declines following orthostatic stress in adults with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), by C Linda M C van Campen, Peter C Rowe, Freek W A Verheugt, Frans C Visser in Front Neurosci. 2020 Jun 26;14:688. [doi.org/10.3389/fnins.2020.00688]

 

Research abstract:

Introduction:

Orthostatic intolerance (OI) is common among individuals with myalgic encephalomyelitis/ chronic fatigue syndrome (ME/CFS).

Cognitive dysfunction has been demonstrated during head-up tilt testing (HUT) in those with ME/CFS: worse scores on cognitive tests occur with increasing tilt angles and increasing complexity of the cognitive challenge. The aim of our study was to determine whether cognitive impairment persists after completion of HUT.

Methods and results:

Eligible participants were consecutive individuals satisfying criteria for ME/CFS who underwent HUT because of OI. The 2- and 3-back tests were performed before the start of HUT and within 5 min after completion of HUT. We measured the percentage of correct responses and raw reaction times before and after HUT for both the 2- and 3-back tests. We studied 128 ME/CFS patients who underwent HUT and had a complete set of N-back data before and after HUT.

Compared to pre-tilt responses, the percentage of correct responses on the 2-back test decreased post-HUT from 77(18) to 62(21) and of the 3-back test from 57(17) to 41(17) (both p < 0.0001). The raw reaction time of the 2-back test increased post-HUT from 783(190) to 941(234) m/s and of the 3-back test from 950(170) to 1102(176) (both p < 0.0001). There was no difference in the N-back test data for subgroups dichotomized based on disease severity, the presence of co-morbid fibromyalgia, or the presence of postural orthostatic tachycardia syndrome.

Conclusion:

As measured by the N-back test, working memory remains impaired in adults with ME/CFS following a 30-min head-up tilt test.

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Severe ME in children

Severe ME in children, by Nigel Speight in Healthcare Vol 8, #3 p 211, July 14, 2020 [This article belongs to the Special Issue ME/CFS]

 

Guideline abstract

The current problem regarding Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (ME/CFS) is the large proportion of doctors that are either not trained or refuse to recognize ME/CFS as a genuine clinical entity, and as a result do not diagnose it. An additional problem is that most of the clinical and research studies currently available on ME are focused on patients who are ambulant and able to attend clinics and there is very limited data on patients who are very severe (housebound or bedbound), despite the fact that they constitute an estimated 25% of all ME/CFS cases.

This author has personal experience of managing and advising on numerous cases of severe paediatric ME, and offers a series of case reports of individual cases as a means of illustrating various points regarding clinical presentation, together with general principles of appropriate management.

 

4. Possible Clinical Features of Severe and Very Severe ME/CFS

  • Minimal energy levels, resulting in the patient being housebound or bedridden;
  • Paralysis;
  • Severe generalised continuous pain;
  • Severe continuous headache;
  • Hyperaesthesia/extreme sensitivity to touch;
  • Abdominal pain, worse after food—this may be so severe as to interfere with nutrition;
  • Sleep disturbance, possible hypersomnolence or difficulty sleeping on account of pain and headache;
  • Major problems with cognition, concentration and short-term memory;
  • Extreme sensitivity to light and sound;
  • Multiple chemical sensitivities;
  • Problems with eating and drinking—this can be due to either general weakness or actual dysphagia, and this may necessitate tube feeding;
  • Aphonia (mechanism unclear);
  • Myoclonic jerks;
  • Incontinence.

 

17. Take Home Messages

  • Severe ME constitutes a major challenge for both patient and doctor.
  • Mismanagement in the form of “activation regimes” can result in permanent harm or even death of the patient.
  • The patient deserves the total commitment of one doctor, who is willing to visit at home on a regular basis.
  • Referral to a psychiatrist who does not believe in ME/CFS can be harmful.
  • The patient should be protected from sensory overload.
  • The doctor should resist the temptation to overinvestigate, or involve too many other professionals.
  • Nursing at home is usually far preferable to admission to a busy general hospital.
  • Tube feeding is indicated when the patient has problems with eating and drinking.
  • Urinary catherization may be helpful in reducing the stress of having to micturate.
  • Symptomatic treatment for pain and sleep problems is worthwhile.
  • Full recovery is possible.
  • The role of immunoglobulin deserves further study [10].
  • There is a need to improve both undergraduate and postgraduate medical training in this area, and to provide greater resources for the patient population affected.
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Health Care responsibility & compassion-visiting the housebound patient severely affected by ME/CFS

Health Care responsibility and compassion-visiting the housebound patient severely affected by ME/CFS, by  Caroline Kingdon, Dionysius Giotas, Luis Nacul and Eliana Lacerda in Healthcare 2020, 8(3), 197 [doi.org/10.3390/healthcare8030197]
[This article belongs to the Special Issue ME/CFS – the Severely and Very Severely Affected]

 

Research abstract:

Many people with severe Myalgic Encephalopathy/Chronic Fatigue Syndrome (ME/CFS) commonly receive no care from healthcare professionals, while some have become distanced from all statutory medical services.

Paradoxically, it is often the most seriously ill and needy who are the most neglected by those responsible for their healthcare. Reasons for this include tensions around the complexity of making an accurate diagnosis in the absence of a biomarker, the bitter debate about the effectiveness of the few available treatments, and the very real stigma associated with the diagnosis.

Illness severity often precludes attendance at healthcare facilities, and if an individual is well enough to be able to attend an appointment, the presentation will not be typical; by definition, patients who are severely affected are home-bound and often confined to bed.

We argue that a holistic model, such as ‘‘Compassion in Practice’’, can help with planning appointments and caring for people severely affected by ME/CFS. We show how this can be used to frame meaningful interactions between the healthcare practitioners (HCPs) and the homebound patient.

Common symptoms affecting people with severe Myalgic Encephalopathy/Chronic Fatigue Syndrome (ME/CFS) seen by CureME:

  • Unrefreshing sleep
  • Disabling fatigue
  • Sleep problems
  • Exercise intolerance (PEM)
  • Pain after exertion/activity
  • Muscle pain
  • Intolerance to standing
  • Concentration problems
  • Difficulty in finding words
  • Difficulty in making decisions
  • Brain fog/cognitive dysfunction
  • Slow thinking
  • Short-term memory problems
  • Difficulty in understanding
  • Difficulty in retaining information
  • Unusual sensitivity to light and/or noise
  • New sensitivities to food, medication, chemicals or odours
  • Intolerance to heat and cold
  • Allergies/hypersensitivities
  • Gastrointestinal symptoms
  • Sickness and nausea               [See Table 1 for more information]

Conclusions

We believe that compassion is central to the care of people with ME/CFS. Despite the current absence of curative treatments for people with severe ME/CFS, the HCP has a responsibility to provide care through a relationship based on empathy, respect and dignity. By supporting the individual with compassion and competence and acknowledging and learning from the patient’s experience, the encounter with the housebound patient can be both effective and worthwhile.

The first step in the therapeutic relationship is to believe and trust the individual: to articulate that you, the practitioner, hear what your patient is saying and recognise that their experience is legitimate.

This severe, complex multisystem disease has long been misjudged by the healthcare profession. Educating practitioners about the needs of those most severely affected by ME/CFS will help drive the step change in understanding and belief, compassion and empathy required to care for all patients with ME/CFS.

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Environmental accommodations for university students affected by ME/CFS

Environmental accommodations for university students affected by myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), by Lily Chu, Lynn R Fuentes, Olena M Marshall and Arthur A. Mirin in Work pp. 1-12, 2020[DOI: 10.3233/WOR-203176]

 

Research abstract:

Background:  Today, 24% of college and university students are affected by a chronic health condition or disability. Existing support programs, including disability services, within colleges and universities are often unaccustomed to addressing the fluctuating and unpredictable changes in health and functioning faced by students with severe chronic illnesses.

This situation is especially difficult for students with lesser-known, invisible diseases like myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), a complex disease affecting up to 2.5 million Americans which often begins in late adolescence or young adulthood.

Objective:  Educate occupational therapists (OTs) about ME/CFS and steps they can take to assist students

Methods:  This work is based on a review of the scientific literature and our collective professional/ personal experiences.

Results:  ME/CFS’ effects on multiple organ systems combined with the unusual symptom of post-exertional malaise frequently and substantially decrease function. Currently, no effective disease-modifying treatments have been established.

Nevertheless, OTs can help students maximize their participation in university life by identifying potential obstacles, formulating practical solutions and negotiating with their institutions to implement reasonable, environmental accommodations.

Conclusions:  Through understanding this disease, being aware of possible support options, and recommending them as appropriate, OTs are in unique position to greatly improve these students’ lives.

Excerpts:

1.3. The valuable role of occupational therapists

A major goal of occupational therapy is to help individual patients live life to its fullest despite injury, illness, or disability [24]. OTs possess the unique skills and experience to assess the obstacles facing students, formulate possible solutions to overcome them, and advocate for those solutions to be put in place. According to one definition of advocacy carried out by OTs,

“Advocacy is a client-centered strategy involving a variety of actions taken by the client and therapist, directed to the client’s environment to enact change for the client such that engagement in occupation is enhanced through meeting basic human rights or improving quality of life” [25].

OTs also bring professional authority that students, families, and caregivers may not possess when advocating for and negotiating accommodations with professional staff and faculty of higher education institutions. This document is intended to serve as a brief, practical resource for OTs working with adult students afflicted by ME/CFS. We will describe what ME/CFS is, basic principles of medical treatment, and how OTs can help. This document is also relevant and helpful for university staff and faculty members.

 

3. Recommended accommodations

3.1. Maintain overall awareness of the fluctuating nature of ME/CFS

(A) Maintain awareness of the waxing and waning nature of ME/CFS and its unpredictability

3.2 Advise students to negotiate accommodations in advance

(B) Ensure that affected students are aware of the need to register with the disability office as early as possible.

(C) Advise students to schedule an appointment with an academic adviser/consultant early in their university years.

(D) Encourage students to communicate with instructors prior to beginning a class.

(E) Encourage students to request assignment flexibility when possible, emphasizing mastery over quantity of work

(F) Help students to minimize travel

3.3. Requests directed to disability and other university offices

(G) Request lecture notes and/or recordings when lectures are not online or otherwise available for review. If no recordings are available, allow students to record lectures on their own

(H) Request examination accommodations ahead of time.

(I) Request flexible scheduling when possible and the ability to miss or leave classes  without penalty when medically necessary.

(J) Request easily accessible rest areas on campus and the right to take opportunities for rest where and when needed.

(K) Request ergonomic furniture and devices, such as desks, chairs, computers, keyboards, computer mice, etc.

(L) Request as much flexibility as allowable for students who have a work assignment, such as a teaching assistantship, or another type of work-like experience, such as an experiential learning course requirement

(M) Facilitate the use of wheelchairs, mobility aids, and other power-driven mobility devices (OPDMDs)

3.4. Advocating for students at a systemic level

The next three accommodations are not under the direct purview of OTs. However, if asked, OTs can bring up systemic changes that universities can implement to improve the situation campus-wide for all students with ME/CFS and even students with other chronic illnesses. OTs can also offer to be a resource for the university.

(N) Provide awareness training to relevant university staff

(O) Arrange for support services,

(P) Ensure that the various university offices that serve students with ME/CFS are working synchronously and in harmony with each other.

Read full paper [uncorrected author proof]

NB Read about the law requiring ‘reasonable adjustments’ in UK education 

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