Treatment avenues in ME/CFS: a split-gender pharmacogenomic study of gene-expression

Treatment avenues in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: a split-gender pharmacogenomic study of gene-expression modules, by Mary G Jeffrey, Lubov Nathanson, Kristina Aenlle, Zachary M Barnes, Mirza Baig, Gordon Broderick, Nancy G Klimas, Mary Ann Fletcher, Travis JA Craddock in Clinical Therapeutics vol 41, issue 5, May 2019, pages 815-835.e6 [https://doi.org/10.1016/j.clinthera.2019.01.011]

 

Research abstract:

doctor holding tabletPurpose:
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a debilitating multisymptom illness impacting up to 1 million people in the United States. As the pathogenesis and etiology of this complex condition are unclear, prospective treatments are limited. Identifying US Food and Drug Administration-approved drugs that may be repositioned as treatments for ME/CFS may offer a rapid and cost-effective solution.

Methods:
Here we used gene-expression data from 33 patients with Fukuda-defined ME/CFS (23 females, 10 males) and 21 healthy demographically comparable controls (15 females, 6 males) to identify differential expression of predefined gene-module sets based on nonparametric statistics.

Differentially expressed gene modules were then annotated via over-representation analysis using the Consensus Pathway database.

Differentially expressed modules were then regressed onto measures of fatigue and cross-referenced with drug atlas and pharmacogenomics databases to identify putative treatment agents.

Findings:
The top 1% of modules identified in males indicated small effect sizes in modules associated with immune regulation and mitochondrial dysfunction. In females, modules identified included those related to immune factors and cardiac/blood factors, returning effect sizes ranging from very small to intermediate (0.147<Cohen delta<0.532).

Regression analysis indicated that B-cell receptors, T-cell receptors, tumor necrosis factor alpha, transforming growth factor beta, and metabolic and cardiac modules were strongly correlated with multiple composite measures of fatigue. Cross-referencing identified genes with pharmacogenomics data indicated immunosuppressants as potential treatments of ME/CFS symptoms.

Implications:
The findings from our analysis suggest that ME/CFS symptoms are perpetuated by immune dysregulation that may be approached via immune modulation-based treatment strategies.

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Comparison of differential metabolites in urine of the middle school students with CFS before & after exercise

Comparison of differential metabolites in urine of the middle school students with chronic fatigue syndrome before and after exercise [Article in Chinese], by Chi AP, Wang ZN, Shi B, Yang XF, Min RX, Song J in Zhongguo Ying Yong Sheng Li Xue Za Zhi. [Chinese journal of applied physiology] 2018 Apr 8;34(4):340-344 349.

Research abstract:

OBJECTIVE:

To study the differential metabolites in urine and the characteristics of metabolic pathway of middle school students with chronic fatigue syndrome (CFS) before and after exercise, and then explain the metabolic mechanism of CFS.

METHODS:

Eight male middle school students (age:17-19) with CFS were selected as the CFS group according to CFS screening criteria of the U.S. centers. At the same time, 8 male health students of the same age from the same school were selected as the control group. They were administrated to do one-time exercise on the improved Harvard step (up and down steps 30 times/min for 3 minutes).

Their urine was collected before and after exercise, and the differential metabolites in urine were detected by liquid chromatography-mass spectrometry (LC-MS). The multidimensional statistical methods were used to analyze the metabolites by principal component analysis (PCA) and orthogonal projections to latent structures-discriminant analysis (OPLS-DA). Finally, MetPA database was used to analyze the metabolites and to construct the correlative metabolic pathways.

RESULTS:

Compared with the control group, the creatine, indoleacetaldehyde, phytosphingosine and pyroglutamic acid were selected as differential metabolites and the contents of those were decreased significantly (P<0.05 or P<0.01) in CFS group before the step movement.

However, 11 differential metabolites in CFS group were selected out after exercise, which were nonanedioic acid, methyladenosine, acetylcarnitine, capric acid, corticosterone, creatine, levonorgestrel, pantothenic acid, pyroglutamic acid, xanthosine and xanthurenic acid in sequence, the contents of methyladenosine and creatine were significantly increased (P<0.05) and the contents of the other 9 differential metabolites were significantly decreased (P<0.05 or P<0.01) compared with the control group.

The 15 differential metabolites mentioned above were input MetPA database in order to analyze the metabolic pathways weighted score. The results showed that the arginine-proline metabolism pathway disorders were detected in the CFS group before exercise, the marker metabolite was creatine. And 3 metabolic pathways disorder were detected in the CFS group after exercise, which were arginine-proline metabolism, biosynthesis of pantothenic acid and CoA, steroid hormone biosynthesis, and the marker metabolites, in turn, were creatine, pantothenic acid and corticosterone.

CONCLUSIONS:

The disorder of arginine-proline metabolic pathway is detected in CFS middle school students before exercise intervention. After exercise, it can be detected that the steroid hormone biosynthetic metabolic pathway, pantothenic acid and CoA metabolic pathways also have metabolic disorders.

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Altered erythrocyte biophysical properties in CFS

Altered Erythrocyte biophysical properties in Chronic Fatigue Syndrome, by Amit K Saha, Brendan R Schmidt, Julie Wilhelmy, Vy Nguyen, Justin K Do, Vineeth C Suja, Mohsen Nemat-Gorgani, Anand K Ramasubramanian, Ronald W Davis in Biophysical Journal, Vol 116, #3, Suppl 1, p 122a, February 15, 2019

Research: abstract:

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a multi-systemic illness of unknown etiology affecting millions of individuals worldwide.

In this work, we tested the hypothesis that erythrocyte [red blood cell] biophysical properties are adversely affected in ME/CFS.

We tested erythrocyte deformability using a high-throughput microfluidic device which mimics microcapillaries. We perfused erythrocytes from ME/CFS patients and from age and sex matched healthy controls (n=14 pairs of donors) through a high-throughput microfluidic platform (5μmx5μm).

We recorded cell movement at high speed (4000 fps), followed by image analysis to assess the following parameters: entry time (time required by cells to completely enter the test channels), average transit velocity (velocity of cells inside the test channels) and elongation index (ratio of the major diameter before and after deformation in the test channel).

We observed that erythrocytes from ME/CFS patients had higher entry time, lower average transit velocity and lower elongation index as compared to healthy controls. Taken together, this data shows that erythrocytes from ME/CFS patients have reduced deformability. To corroborate our findings, we measured the erythrocyte sedimentation rate for these donors which show that the erythrocytes from ME/CFS patients had lower sedimentation rates.

To understand the basis for differences in deformability, we investigated changes in the fluidity of the membrane using pyrenedecanoic acid and observed that erythrocytes from ME/CFS patients have lower membrane fluidity. Zeta potential measurements showed that ME/CFS patients had lower net negative surface charge on the erythrocyte plasma membrane.

Higher levels of reactive oxygen species in erythrocytes from ME/CFS patients were also observed. Using scanning electron microscopy, we also observed changes in erythrocyte morphology between ME/CFS patients and healthy controls.

Finally, preliminary studies show that erythrocytes from ‘recovering’ ME/CFS patients do not show such differences, suggesting a connection between erythrocyte deformability and disease severity.

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Assessment of the scientific rigour of randomized controlled trials on the effectiveness of cognitive behavioural therapy & graded exercise therapy for patients with ME/CFS: a systematic review

Assessment of the scientific rigour of randomized controlled trials on the effectiveness of cognitive behavioural therapy and graded exercise therapy for patients with myalgic encephalomyelitis/chronic fatigue syndrome: A systematic review, by SA Ahmed, JC Mewes, HJM Vrijhoef in Journal of Health Psychology [First Published May 10, 2019] https://doi.org/10.1177/1359105319847261

Review article abstract:

Cognitive behavioural therapy and graded exercise therapy have been promoted as effective treatments for patients with myalgic encephalomyelitis/chronic fatigue syndrome. However, criticism on the scientific rigour of these studies has been raised.

This review assessed the methodological quality of studies on the effectiveness of cognitive behavioural therapy and graded exercise therapy.

The methodological quality of the 18 included studies was found to be relatively low, as bias was prominently found, affecting the main outcome measures of the studies (fatigue, physical functioning and functional impairment/status).

Future research should focus on including more objective outcome measures in a well-defined patient population.

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Varied presentation of ME/CFS & the needs for classification & clinician education: a case series

Varied presentation of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome and the needs for classification and clinician education: a case series, by Eva Martín-Martínez, & Mercedes Martín-Martínez in Clinical Therapeutics vol 41, issue 4, pages 619–624, April 2019

Abstract:

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a complex, heterogeneous and serious disease.

In this article, we analyze the cases of 3 patients with ME/CFS. Due to the disbeliefs, misconceptions, and stigmas that are attached to ME/CFS, patient diagnosis is made after years of disease progression. Over this period, physicians tried to determine the etiology of the disease, taking into account its onset and symptoms.

The suspected conditions correlated with possible subgroups that researchers speculate may exist in ME/CFS. Therefore, a registry of well-selected data on clinical history could help to cluster patients into more homogenous groups, and could be beneficial for research

Conclusions:

The three cases reported highlight the need of a better medical training to get early diagnosis and a better management of the disease, and in this way it will be also possible to get samples in the early stages of the pathology.

Interestingly, in these clinical cases, the onset correlate with several of the different approaches researches followed: immune, inflammatory, genetic or metabolic disease. Therefore, clinicians can contribute to the generation of subgroups of ME/SCF patients based on clinical presentation and the occurrence of comorbidities.

To this aim, a complete clinical history should be obtained and a minimum of variables should be registered: triggers, onset, localized or generalized affectation, existence of family history, degree of disability, and comorbidities.

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In the news: Missing from their lives, missing from healthcare services

ME Awareness week – in the BBC news in Wales

“All round the world millions of people are missing from their lives. In Wales people are also missing from the healthcare system.  When we go to the surgery we’re not always treated with respect. Sometimes our illness is dismissed. Too few GPs have the knowledge to diagnose accurately and for those who are bedbound and housebound they can’t always get anyone to come and visit them ,so basically we feel invisible and ignored.”                                                                  Jan Russell, chair of WAMES

BBC Wales featured ME on the radio, TV news and online on 10th and 11th May 2019.

BBC Radio Wales: Good Morning Wales, 11 May 2019. The programme covered the nature of ME, healthcare in Wales & the #MillionsMissing event.

  • An interview with Clare Ogden from AfME took place between 05:40 – 10:00 minutes.
  • From 36:40-43:20 Jan Russell from WAMES spoke and parent Alana Sargent from Tylerstown was interviewed.

 

BBC Wales: Wales Today on Sat evening, featured the #MillionsMissing event in Cardiff, Marian Gray from Aberystwyth,  comments from Jan Russell of WAMES and Emelyne Burkhardt from MESiG from 02:00 – 04:12.

 

BBC news online: Humanitarian crisis for ME sufferers in Wales. The online article covers how people go missing from their lives, GPs find it difficult to diagnose & little improvement has been seen in service development. Comments from Marian Gray from Aberystwyth, Jan Russell from WAMES, Miriam Wood from MESiG and Dr Peter Saul from the RCGP.

“People thought I’d moved away or joined a nunnery”, said Marian Gray, who admits going “missing from life”.

She disappeared because she was one of the 13,000 people in Wales battling ME.

Campaigners say there is a “humanitarian crisis” and promises of better support from the Welsh Government have failed to materialise.

 

 

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BBC Wales news: ‘Humanitarian crisis’ for ME sufferers in Wales

BBC Wales News article, 11 May 2019: ‘Humanitarian crisis’ for ME sufferers in Wales

 

“People thought I’d moved away or joined a nunnery”, said Marian Gray, who admits going “missing from life”.

She disappeared because she was one of the 13,000 people in Wales battling ME.

Campaigners say there is a “humanitarian crisis” and promises of better support from the Welsh Government have failed to materialise.

On Saturday, Cardiff joins 300 places around the world is holding an event for ME awareness week, with empty shoes symbolising people missing from life.

“I’m a profoundly sociable person but people in Aberystwyth thought I’d moved away or joined a nunnery because they hadn’t seen me in the places they should see me,” said Ms Gray.

“I had to leave my mountain biking shoes, my violin playing shoes.

“To continue working, I had to empty my life of anything else, including a social life.”

Myalgic encephalomyelitis (ME) or Chronic Fatigue Syndrome is usually triggered by a viral infection which leads to muscle fatigue, pain and neurological symptoms such as short term memory loss.

About 13,000 people in Wales are thought to suffer from ME, and 70% of those are women.

Ms Gray, an international officer at Aberystwyth University, first had symptoms at primary school – but more than 30 years later, she says little has improved.

“The dialogue has not changed,” she added.

“The doctor says ‘you have this diagnosis but there is nothing we can do’.”

By being allowed to work from home at times, she manages a career – but said some people suffering severe symptoms cannot bear bright lights or being around loved ones.

“There is a humanitarian crisis in the healthcare system,” said Jan Russell, who has suffered with the condition for 30 years.

“There is 13 to 15,000 people with ME in Wales, 25% of which are severely affected.

“In Wales people are missing from the healthcare system, and when they go to the surgery, not always treated with respect.”

Ms Russell, who is chairwoman of Working for ME in Wales, said few GPs had enough knowledge of the condition – and those left housebound felt “invisible and ignored”.

“You are lucky if you can find a doctor who has an understanding of ME,” said Miriam Wood, a former NHS worker who is part of Cardiff-based ME Support in Glamorgan.

“They might be thinking the person is depressed and just give them antidepressants.”

Ms Wood said the First Minister Mark Drakeford had pledged to create a pathway for people to get help more easily when he was health minister between 2013 and 2016.

“We have been trying to find out what progress has been made but haven’t been able to,” she said.

“We are still in the same place we were all those years ago when Mark Drakeford said changes would be made.”

‘Invisible condition’

A Welsh Government spokesman said: “We understand the challenges faced by people living with this condition and the impact it can have on their lives and their families.

“That is why we are working with healthcare professionals and the third sector to strengthen ME services available across Wales.”

Royal College of General Practitioners chairman Dr Peter Saul said ME is very difficult to diagnose and distinguish from other conditions.

“It can take longer to diagnose it than other conditions but patients should not feel that they are being ignored or dismissed,” he added.

“It is a sort of invisible condition for which there are no quick medical treatments.”

Read the full article with all the links

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Cardiff University plans research into ME/CFS using ME/CFS Biobank samples

CureME (leading research into ME) blog post: Biobank users

Samples from our Biobank are available to external researchers around the globe. Making these samples available to other researchers increases the chances of achieving much-needed breakthroughs in the aetiology and treatment of ME/CFS, in the most cost-effective manner.

Here are our current collaborators, and their stories:

Professor Duncan Baird is a geneticist with an interest in telomere biology and genome stability, based at Cardiff University. Telomeres are the structures that cap the ends of linear eukaryotic chromosomes. Due to a quirk in the way that DNA is replicated, as cells divide and as we age, telomeres become progressively shorter, ultimately obtaining a length at which they become dysfunctional and trigger the cells to enter a non-dividing state called replicative senescence. Telomeres therefore provide a limit on the number of times cells can divide.

This project hopes to provide an in-depth understanding of cellular ageing of immune cells in patients with ME/CFS and whether this may impact on the pathology of this condition. Providing an understanding of these processes and the technologies to monitor them may in turn lead to prognostic tools and potential therapeutic interventions.

The samples released to Professor Baird were distributed free of charge, as one of the two awardees from the UKMEB’s Christmas Appeal 2017/18, to enable priority research to happen without cost being a barrier. Thank you to everyone who donated.

Read about more recipients of Biobank samples

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ME awareness – in the workplace

Explaining ME in the workplace

Raising awareness of ME is always a good idea – yes? 

But is telling others about your experience of ME always a good idea?

There are many creative ways to describe to friends and family how ME affects the way you feel and disrupts your life. You might unfortunately fear that being so forthcoming with your employer, line manager or work colleagues may backfire, causing them to lose confidence in you, could lead to resentment or bullying, or affect your prospect of promotion or job development.

You are not obliged to disclose any health issues to an employer unless it could lead to health and safety problems.  You may feel you have to give some explanation however if you decide that ‘reasonable adjustments’ or changes in your workplace or work routines will be necessary to avoid relapsing, to enable you to continue working, or be effective in your job. You can also ask your employer or line manager to keep the fact of your illness confidential, and s/he is obliged to do so, when practical.

Many written introductions to ME highlight the severity and long term nature of the condition, which may not aid your employer’s understanding of your needs if you are mildly affected. Though your employer may have access to NHS, DWP or Union leaflets about CFS, so you should be ready to explain exactly how ME affects you, how this could affect your ability to do your job, and if necessary, how your approach to treatment and management differs from NICE recommendations!

Research employment & disability

Do some research or consult an advisor to find out about your rights and your employer’s responsibilities as this might affect what and how you disclose – a good place to start is the ME Association’s leaflet: Employment issues and ME/CFS

Pitch the info at the right level

Any leaflets or videos about ME you offer your employer should be short & easy to digest – the Canadian guidelines for clinicians might be overkill! You can always give more information later once you know what they want or need.

Decide how much info to give

If you tell your employer you are recovering from a severe phase of ME, then you will probably have to give them a lot more info about the illness and ask for more support, than if you are requesting one or two adjustments to your work practices in order to enable you to keep on an even keel and avoid relapse. Read the ME Association’s leaflet for ideas on Explaining ME/CFS to other people

Decide which info to give

Try to work out the key triggers that will make your symptoms worse and which adjustments could help. A US article gives some suggestions: Working with Chronic Fatigue Syndrome & Myalgic Encephalomyelitis   You may need to provide your employer with information about specific difficulties so s/he can suggest feasible changes e.g. for sensory overload, activity pacing, pain, mobility & travel, cognitive problems.  It may not be necessary to mention ME at all if you only need adjustments for a symptom that is common and easily understandable e.g. migraines, back pain

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