Tuesday, May 22, 2012
Novel MLV-GAG sequences detected in blood samples of ME/CFS patients
From the Hanson lab, this paper published today in PLoS ONE describes a study carried out with meticulous attention to detail and proper use of controls while analyzing ME/CFS patient samples for murine-leukemia related viruses. Although novel MLV-like GAG sequences were isolated and sequenced from the patient samples (as opposed to controls collected from the same sites) Lee et al. concludes that it is not possible to determine the origin of these sequences, although the samples were not contaminated with mouse DNA at a detectable level. First, bravo! to the Hanson group for being able to get anything published that might go against the current dogma regarding MLV-like viruses in human samples published -- I guarantee you that there are people with similar data whom don't want to torture themselves by attempting to publish. The fact is, that it seems somehow MLV-like nucleic acids somehow end up in patient samples quite a bit, albeit at exceedingly low levels. Theoretically, even if there was an MLV-type infection in a human, it would be rapidly eliminated (unless of course we don't know everything about the immune system yet). I wonder if it is possible that such viruses could hide somewhere in the body, not replicating much - perhaps killing host cells occasionally resulting in a release of (potentially degraded) viral nucleic acid that is ultimately detected in the blood stream. I haven't analyzed these sequences yet compared to those we have detected in tissue samples from BPH patients, but seeing as our sequences were recently published on the USPTO website, someone else will probably try that. The link to the Hanson paper is here --
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I would kindly suggest that you parse table 4 of the "addendum" by the doctors Mikovits and Ruscetti from the year 2010. Please do report what you find.
ReplyDeleteTony, I suspect you are referring to Mikovits et al. In which table four includes only 94 of the 101 patients from Lombardi et al. If you read both papers the reason is obvious. Mikovits et al. does not include any testing that was only performed at Dr Silvermans lab at the Cleveland clinic.
ReplyDelete1. No, it is actually 93 patients in table 4, not 94.
Delete2. No, the reason is not "obvious".
3. That is actually not the reason why you should read table 4.
Have fun.
It is not 93. Recount please. You need to read all the tables. None of that works was performed by Silverman.
DeleteTry this way. Write out each number once. You are wrong.
Patient 1199 is not in table 4, but they are in table 1 and table 2. I suggest Tony that you don't make such comments again. You have no excuse to.
Deletehttp://www.landesbioscience.com/journals/virulence/MikovitisVIRU1-5.pdf
Dr O'Keefe, I just wanted to thank you for displaying what appears to be an increasingly rare trait amongst today's researchers: an open mind.
ReplyDeleteThank you Dr O'Keefe,
ReplyDeleteEvery piece in the puzzle helps and keeping an open mind seems to be a rare things in scientists considering MLV infection in human.
I am aware of one such positive but unpublished study that was done under the umbrella of NIH - it found positives in autism samples, but later decided that "it must be contamination" (because CDC/Willams study said so!) and never published. Since they never published and didn't share details with me I don't know if they found positives in controls etc.
ReplyDelete“... Dr Mike Iadarola is now ready to run the XMRV assays on samples from our children with autism (approx 100), typical development (60) and developmental delay (30). We did send him a batch of approximately 100 samples last summer (from the three groups), almost immediately after the initial report of the positive results in autism (ref. Mikovits unpublished results). However, that assay proved to be quite unreliable, yielding positive results in individuals who were known to be negative by more extensive testing. So, we elected to wait for the assays to be better standardized before running our children's sample. Meanwhile, we finished enrolling subjects in the phenotyping study and Dr Iadorola can now run the assays on the whole cohort..."
In later correspondence, when I asked about how they decided that their assay “was unreliable” and what they meant by “yielding positive results in individuals who were known to be negative by more extensive testing” --- Dr Iadorola only mumbled something about CDC/Satterfield study (see quote below) and never gave me a straight answer.
My repeated question as to why they refused to publish their initial results was also NEVER answered. It would be very interesting to know what “extensive testing” was carried out and by whom/how, what was the ratio of patients to controls with initial positive results etc…
This is the reply from Mike Iadorola on my question as to why they didn’t publish their positive findings:
[QUOTE]“ …. Please look at this recent paper from Molecular Autism (attached). They used PCR to look for XMRV DNA and did an antibody test. The results were uniformly negative: no XMRV in autism samples (and they had plenty, some from USA, some from abroad. Thus, my projection is that we likely will corroborate their study. We will examine the serum for the presence of antibodies to couple of XMRV proteins. The assay we developed is called Luciferas Immunoprecipitation systems..."
So totally avoiding explanation of his own POSITIVE results, no explanation on why not publish them...
Not sure what happened to this second study – the one he expected will “likely corroborate” the negative studies - I suspect if they did find positives they would be very reluctant to publish, wouldn't they? But I suspect if they DID found all their samples negative they would be very keen to publish, no?
Btw this NIH/Iadorola communication is from November 2010. (head of NIH Collins was copied in all it, and so were one or two other senior figures, so cannot plead ignorance...)
ReplyDeleteYes I heard of another positive study. In the UK 50 ME/CFS blood samples were drawn at Ashford hospital London back in 2010.
ReplyDeleteThey were blinded and sent to the NCI USA, a lot of these samples tested positive.
This is the unpublished Mikovits/Ruscetti study showing retroviruses in autistic children and their families. This was before Silverman's error in virus identification came to light, so it is unknown what tropism these sequences have.
ReplyDeleteDetection of infectious XMRV in the peripheral blood of children
19 adults with CFS, FM and/or Lyme disease; 18 parents of children with neuroimmune disease; 17 children with ASD; 2 children with Niemann- Pick C; 10 healthy children with siblings who have neuroimmune disease
Serology for antibodies to XMRV env using PCR and RT-PCR on cultured PBMC nucleic acids, plasma isolation of XMRV to LNCaP cell line.
36/66 (55%) overall; 17/29 children (58%); 20/37 parents (54%); 14/17 autistic children; 2/2 Neimann Pick type C
Canadian (for CFS)
XMRV is observed in children with a wide spectrum of neuroimmune disorders and their family members. The significance of these findings is not clear.
http://www.cfids.org/xmrv/wrkshp-data-comparison.pdf
I see several groups finding the viruses with their assays and others not finding the viruses with different assays. Some wrongly complained at the start that the WPI was not sharing reagents, which they were. Isn't it about time that these groups using assays that are not clinically validated and have never been demonstrated to work, replicated the proven clinically validated methods of these other groups? Also, how can the blood supply be declared safe when not one PCR assay was clinically validated in that study?
I love your chutzpah! Refreshing to encounter an inquiring mind not afraid to voice opinions and questions.
ReplyDelete"a release of (potentially degraded) viral nucleic acid that is ultimately detected in the blood stream"
ReplyDeleteIs this like the Biolab or Acumen Cell Free DNA test?
thanks
That is nothing to do with assays. It is a hypothesis for how the viruses behave. 98% of the virus would be expected to be in tissue reservoirs. This is why some MLVs have never been detectable in blood.
Delete"I wonder if it is possible that such viruses could hide somewhere in the body, not replicating much - perhaps killing host cells occasionally resulting in a release of (potentially degraded) viral nucleic acid that is ultimately detected in the blood stream."
ReplyDeleteThis seems to be what the study done at Emory suggested. The virus was all but undetectable in the blood after a few weeks, but could still be recovered from various tissues. Someone should do a similar study looking for gamma-retroviruses in the tissues of humans suspected of harboring XMRV (CFS, cancer, etc.)
The Monkey study, that is:
Deletehttp://www.ncbi.nlm.nih.gov/pubmed/21325416
Yes, many studies on tissue should be done.
DeleteThank you for your blog and for investigating potentially extremely important topics.
ReplyDeleteMany people are suffering and dying and their diseases are not getting researched.
Whether any given result is positive or negative, we need rigor and a real answer we can scientifically trust and investigation.
It is a delight and a relief and greatly appreciated when we see people interested in doing those things.
I loled at "(unless of course we don't know everything about the immune system yet)". :)
(Strike that word "potentially".)
ReplyDeletethanks for reading my blog everyone, I think it is important to keep an open mind...and yep Samuel, I did make that comment about the immune system "tongue in cheek"...
DeleteEven better– That paper says they cant find LTRs. They can't find pol. They can't find env. A retrovirus without LTRs, pol, or env! How intriguing!
ReplyDeleteBut sometimes they ‘found gag’… but then they couldn't later find gag. And sometimes ‘gag’ turned out to be non-specific amplification of human DNA. And sometimes ‘gag’ was mouse DNA. And in all other times, they ‘found gag’… which was only a nucleotide or two different from endogenous mouse viruses (Lo et al).
The paper doesnt overhype or overstate what they found
The only patients stated to be positive were those diagnosed by Dr Bell, who uses the Canadian criteria for ME. The Levine patients were all negative. Levine diagnosis using the Fukuda CFS definition. The gag was detected in Bells patients, but was not confirmed in Levine's. You have misunderstood. Single round PCR was also used on Levine's and Nested PCR on Bells. Levine's were negative. Two issues are apparent. Selection criteria of the clinicians and the sensitivity of the PCR assay.
Delete" We therefore obtained a second set of samples from the office of Susan Levine, M.D. in Manhattan, New York. Single-round gagL PCR was performed on gDNA, and all assays were negative."
At no times was mouse contamination confirmed in the study. You should read again.
The Lo sequences were also never found to be contamination. You have that wrong also.
The env region looked for in the Bell samples was only XMRV. Mikvoits and Ruscetti were also unable to detect env regions of XMRV, but have found env regions of different MLV-reatled viruses.
These env and pol assays were not validated using a known positive. The gag assay that detected positives in Bells cohort was. The primers used in those pol, LTR and env assays that failed to detect the viruses were also generic primers.
All assays need to be clinically validated.
it is interesting that everyone, us included, seems to have much more trouble amplifying the env and LTR regions - if gag amplification was merely due to mouse contamination, why don't these regions amplify as well? Keeping in mind that tests for mouse DNA are coming up negative...this might suggest that there is more divergence from known MLV-type sequences in these regions - we managed to sequence the variable region of env from one patient -- the sequence was most similar to env from an MLV virus known to cause disease in mice in the wild -- which is pretty interesting if you think about it...
ReplyDeleteThe env sequences that were uploaded to the Genbank before Dr Mikovits left the WPI have 76% homology to one another.
DeleteThe recombination rate of MLVs is also similar to that of HIV.
"The cause of these differences in recombination frequencies is puzzling because RTs from SNV, MLV, and HIV-1 have similar template switching rates as mentioned above. This is further supported by the observation that multiple crossovers are often observed in SNV and MLV recombination, even though such events should be exceedingly rare based on their recombination rates [7,81]. " http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3187697/
High rate of genetic recombination in murine leukemia virus: implications for influencing proviral ploidy.
http://www.ncbi.nlm.nih.gov/pubmed/16775360
Figure 9 of this paper may be interest to you.
"Similarity Plot of Full-length MuLV genomes: Plots of similarity between the MuLV 1313 genome (the 'query' sequence) and 10 representative, full-length MuLV genomes (the 'reference' sequences) present in the GenBank database were generated by SimPlot [72]. "
Molecular and phylogenetic analyses of a new Amphotropic murine leukemia virus (MuLV-1313). 1006. Thomas M Howard, Zhijuan Sheng, Mingwu Wang, Yongchun Wu, and Suraiya Rasheed
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1769482/
Interestingly no wild mice have ever been tested for the presence of MLV-realted viruses, only lab mice and lab mice derived from wild mice.
DeleteMLV env's are more divergent.
Delete" All env genes occupy a common genomic location downstream from the gag and pol genes, they are expressed via spliced mRNAs, and they have an organization similar to that of precursor proteins, with several common structural features. Nevertheless, they exhibit considerable sequence differences from one another."
http://www.ncbi.nlm.nih.gov/books/NBK19393/
I asked a question about NIH-3T3 cells in response to this comment and it was deleted. Was this an accident and if not, may I ask why my question was deleted? Thanks.
DeleteWhile I also believe there must be tissues that are better reservoirs than PBMC, I have mentioned another possibility for results that are difficult to replicate. These immune cells are constantly responding to changes in the environment and internal milieu. They are very likely to carry latent viruses like EBV. There are plenty of patients in which these are activated.
ReplyDeleteIf someone is detecting DNA fragments related to MuLV RNA viruses without detecting DNA from mouse cells we have a paradox. There will always be the possibility PCR is stitching together a crazy-quilt sequence which is not present in the sample from short fragments. This causes me to put more reliance on consistent long sequences like the ones in your patent.
If a retrovirus is active at some place you are not sampling, like prostate tissue or bone marrow, the possibility it might insert DNA in an episome resulting from an endemic DNA virus should be considered. This kind of modified DNA could be transferred between immune cells via immunological synapses even if the inserted sequence is replication defective. Ultimately, I would expect the DNA virus to eliminate such genes, because they are not essential for its survival, but in the short run, inside an infected patient, a variety of such junk could easily persist.
Retroviruses inserting genes, even complete functioning genomes, in DNA viruses have been observed in other species. Avian reticuloendotheliosis virus has put itself in pox viruses. Other retroviruses have inserted themselves in herpes group viruses.
Why should this be considered impossible in humans?
anciendaze
If I recall, weren't the patients selected for Lombardi et al "highly viremic," which would mesh well with this argument?
DeleteWhere do you think you heard that?
Delete"Patient samples. Banked samples were selected for this study from patients fulfilling the 1994 CDC Fukuda Criteria for Chronic Fatigue Syndrome (S1) and the 2003 Canadian Consensus Criteria for Chronic Fatigue Syndrome/myalgic encephalomyelitis (CFS/ME) and presenting with severe disability. Samples were selected from several regions of the United States where outbreaks of CFS had been documented (S2). These are patients that have been seen in private medical practices, and their diagnosis of CFS is based upon prolonged disabling fatigue and the presence of cognitive deficits and reproducible immunological abnormalities. These included but were not limited to perturbations of the 2-5A synthetase/RNase L antiviral pathway, low natural killer cell cytotoxicity (as measured by standard diagnostic assays), and elevated cytokines particularly interleukin-6 and interleukin-8. In addition to these immunological abnormalities, the patients characteristically demonstrated impaired exercise performance with extremely low VO2 max measured on stress testing. The patients had been seen over a prolonged period of time and multiple longitudinal observations of the clinical and laboratory abnormalities had been documented." Lombardi et al. SOM.
The Canadian criteria for ME was applied first, the Fukuda criteria second. The other way around can cause all Canadian criteria patients to be filtered from a cohort.
Um- how do we know the 'Fukuda' criteria were applied 'second' to the Canadian? Doesn't that conflict with what we know about both Fukuda and Canadian: that Leonard Jason has shown the Canadian to be STRICTER than Fukuda in that it separates out a more physically impaired research/clinical population? I don't see how Fukuda could be used as a SECOND step in selecting patients, when they have already been selected by stricter criteria (Canadian).
ReplyDeleteOne problem with the use of Fukuda is that some research studies do not use it correctly, i.e. they do not EXCLUDE patients with signs of physiological impairments, which technically they should. Reeves 2003 clarifies the prescription of Fukuda to exclude patients from a diagnosis of CFS if they have any physical signs of illness. Canadian criteria do not.
Dr Mikovits has always confirmed when asked that the Canadian criteria was applied first. She has stated this at conferences. This is what Peterson uses.
ReplyDeleteThere is no requirement in the Fukuda criteria to exclude signs of physiological impairement. Reeves 2003 is not the Fukuda 1994 criteria, and that was not used to select the patients in Lombardi.
Patients selected with the Canadian have been shown to be more physically impaired then with Fukuda. Where Fukuda falters is in its ability dependant on the bias of the selector to include Canadian criteria patients. It is such a broad definition, allowing for those with depression, it cannot be said with any certainty that a cohort of Fukuda people (fatigue and four minor symptoms) will ever include a single Canadian patient. Select Canadian ME patients in the first round controls the cohort rather than leaving to chance who is enrolled in a study.
If you wanted to select from the human race people from Japan, you would not ask for people with black hair, as that is too broad and the chance of selecting any Japanse person is very slim.
@ anonymous (May 25 5.16 pm):
ReplyDeleteIf it really is the case that Mikovits claims the Canadian criteria were applied first (I think we need more substantive evidence than hearsay at unidentified conferences!) then that would be extremely odd.
It would be like first selecting penguins on the basis of being flightless birds who have specific features related to size, mode of transport, colour, habitat, then secondly throwing open the selection to include ostriches because they are flightless birds. It doesn't make sense.
Re your claim about Fukuda not excluding physical signs. As with the Oxford definition, the devil is in the detail in the game of semantics that most CFS criteria exhibit. Fukuda does say: "Any unexplained physical examination finding or laboratory or imagining test abnormality that strongly suggests the presence of an exclusionary condition must be resolved before further classification". Therefore this allows - even prescribes - the exclusion of patients with signs of physiological impairment.
I know Reeves 2003 was not used in Lombardi (it was used in PACE). It is interesting that Reeves 2003 clarify about any physical signs prompting the search for alternative diagnosis. Clearly Fukuda's paragraph was open to differing alternative interpretations, though again - this is a game of semantics.
I actually agree with much of your third paragraph by the way. Selection of Canadian (or ICC) was best way of controlling the cohort, as Fukuda is too wide (yet at the same time exclusionary!)
Such is the madness of the 'CFS' criteria and their determination to exclude physiologically impaired ME patients from the research.
The first negative XMRV paper by Erlwein et al demonstrate that determination extremely well.
Why would it be odd? The patients in Lombardi et al. were definitely selected with the Canadian and then the Fukuda was used to see if they met that. Most Canadian criteria patients are going to fit the Fukuda, but definitely not the other way. Once you have that first set of Canadian patients you cannot go outside that group when then using Fukuda. It makes perfect sense.
ReplyDeleteFukuda says an unexplained finding which can be explained by an exclusively condition must be resolved first. It does not saying findings that cannot be explained are excluded. It also does not exclude those findings that could be another disease but have resolved, ie. shown to not be another disease, those patients can be included.
I would say ask Mikovits for confirmation, but she is gagged. You could try Dr Ruscetti. Either way, it is correct, the Canadian criteria was applied first.
The ICC (International criteria) was not used, and we have no data if that selects the same patients as the Canadian. If a study used that it would not be a replication either.
Hopefully that explains it.
@ anon,
ReplyDeleteNo - it does not 'explain it' at all, and my analogy of the penguin and flightless birds shows why.
But you do highlight why, semantically, Reeves et al 2003 were developed to 'clarify' Fukuda. To definitively explain 'away' a sign (or indeed symptom) as being NOT due to something else, it would take a massive undertaking in terms of investigation, something Fukuda actually proscribes, strongly!
Now- we need to remember Fukuda is a RESEARCH definition, not a CLINICAL definition. Because of this, added to the exhortation NOT to investigate thoroughly, the only logical option (and indeed, it appears the whole reasoning behind the CFS RESEARCH criteria such as Fukuda, Reeves, Oxford) is to EXCLUDE patients showing signs of physical dysfunction OUT of research cohorts, nice and promptly, in order to avoid 'wasting' time and money on further investigation (I'm not advocating that - I'm showing it as a massive problem in ME/CFS research and clinical practice).
This appears to have been done in the PACE trial, for example, and was done in the Erlwein et al negative XMRV study, except the cohort in Erlwein were a previously identified cohort who had undergone extensive testing to more 'perfectly' exclude signs of organic physiological dysfunction for other studies.
Most likely, Mikovits et al (perfectly reasonably) used the Canadian Criteria as the INCLUSION criteria. People fulfilling Canadian Criteria ALREADY fulfill Fukuda BAR the requirement to EXCLUDE those with signs and symptoms of physical.
Whereas those research teams favouring psychogenic explanations for ME/CFS (and wishing to exclude possible explanations such as a retrovirus) DO appear to use every possible avenue to EXCLUDE patients with signs (and/or symptoms) of organic physiological dysfunction, those looking towards more biomedical explanations do seem to treat Fukuda as a clinical criteria, and use in the way you suggest (i.e. include people with signs and symptoms of physical dysfunction not necessarily immediately explained by other illnesses), though not always!
This may explain why cohorts are so heterogeneous globally, and all the confusing findings in all aspects of studies on ME/CFS (or 'CFS/ME' or 'CFS!)
I don't think you can confidently claim Mikovits or Ruscetti will back up YOUR claim here. What is more I don't think you should be doing this. If you cannot substantiate your claim clearly, then you cannot confidently insist Fukuda was applied 'secondly'.
To others taking part in this blog discussion - the reason this all matters is because one neglected aspect of all the negative 'XMRV' studies is how patients were selected, or excluded, from the research cohorts, and how they may (and often do) differ from the 'positive' MRV study cohorts. It also explains why strict ME/CFS criteria such as Canada or the ICC should be used in future research.
Mikovits and Ruscetti would confirm the Canadian criteria came before the Fukuda. Peterson uses the Canadian to diagnose ME. No doubt there will be a record of this on the web some place, probably one of her presentations. I will look, because I prefer not to leave this hanging. I can confidently say I have seen Mikovits say repeatedly that the Canadian criteria was the primary diagnosis in Lombardi et al.
DeleteI agree with you that this does matter, because using only the Fukuda criteria has little hope of capturing those patients who are most likely to be infected with a MRV. Using the Fukuda as the primary criteria can totally empty a cohort of Candian patients. What other retrovirus study even looked Canadian patients.
But one other thing for you to consider while I look is that the patients in Lombardi et al. had characteristic abnormalities in Vo2. The chances of getting a Fukuda cohort with that without them having a primary Candian criteria diagnosis is slim.
Your bird analogue I understand but it does not apply to this because as I explained Fukuda only requires that the unexplained physical findings or tests be resolved, ie. shown to not be another disease. They only need run the tests approved by the authorities at this time to rule out other diseases.
"Any unexplained physical examination finding or laboratory or imagining test abnormality that strongly suggests the presence of an exclusionary condition must be resolved before further classification".
Reeves 2005 may have drawn from Fukuda 1994, but when Fukuda is applied it is not Reeves 2005. So Reeves 2005 is not related to Lombardi et al.
" it appears the whole reasoning behind the CFS RESEARCH criteria such as Fukuda, Reeves, Oxford) is to EXCLUDE patients showing signs of physical dysfunction OUT of research cohorts"
Yes, I wholeheartedly agree.
"Most likely, Mikovits et al (perfectly reasonably) used the Canadian Criteria as the INCLUSION criteria. People fulfilling Canadian Criteria ALREADY fulfill Fukuda BAR the requirement to EXCLUDE those with signs and symptoms of physical."
I still disagree here. There is another legitimate interpretation that if the findings cannot be linked to another disease they can be included. That is why Candian patients can fit the Fukuda criteria. Switch those around and a Fukuda cohort can contain no Canadian patients.
There is this also.
Delete"Patient selection poses a challenge to any study of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). In our October 2009 paper, samples banked from 2006 to 2008 were selected for our study from severely disabled patients who fulfilled the 1994 CDC Fukuda Criteria for chronic fatigue syndrome1 as well as the 2003 Canadian Consensus Criteria (CCC) for ME/CFS.2 The CCC requires post-exertional malaise, which many clinicians feel is the sine qua non of ME/CFS. Furthermore the CCC further requires that patients exhibit post exertional fatigue, unrefreshing sleep, pain and neurological/cognitive manifestations, rather than these being optional symptoms.3 Many clinicians interested in CFS are switching to the Canadian criteria because they feel it is more descriptive of the clinical entity being defined. The Fukuda criteria have the advantage of a longer period of usage and existence of many publications that have added modifications. Suffice it to say that the clinician author of the Science paper elected to use both criteria, thus bypassing the argument of which criteria were better. Moreover, the emphasis in the Science paper was directed toward the virology, not the clinical description of ME/CFS."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073172/
Perhaps try thinking this way. Explain how you can give a primary diagnosis of fukuda which satisfies the CCC requirements?
DeleteHere you can see he work was replicated for the UK study.
Delete"And so what I’m showing you here is that if we applied the techniques, that PCR I just showed you here, to a cohort of 50 patients in the UK… what I’m looking at here is patients who are similar to you, to the patients in the original study. They are largely homebound. They clearly can’t work. Many of them are homebound and bedridden, so we had an independent phlebotomist go and draw (blood from) the patients that fit the criteria, the most rigorous Canadian Consensus criteria. But we also looked at things like acute flu-like onset, and people who told us there were several in the family. "
https://www.facebook.com/note.php?note_id=10150103870586797
Here again the Canadian.
Delete" And importantly, this cohort was selected with that strict criteria for illness, definitely meeting the Canadian Consensus Criteria. But these patients were largely homebound, if not bedridden. The blood was collected by an independent phlebotomist in or near their home."
http://www.mecfsforums.com/wiki/Transcript_of_Mikovits_talk_at_NIH_Workshop_(7_April_11)
None of what you have said substantiates your claim that Lombardi et al carefully selected Canadian Criteria compliers first, then had to carefully select Fukuda compliers second FROM the Canadian complying cohort. It doesn't make sense, because of what I've said above.
DeleteIf anything - your evidence above points to Fukuda being used FIRST (as logically it 'should' be.)
Lombardi et al representatives have been VERY quiet about the selection criteria, apart from the additional info to the paper. I actually did ask Mikovits for further info and a specific question but she declined. This is not to accuse her of any malfeasance. But just that I'm not confident that any of the 'would' confirm your claim - and that you can't second guess them like that.
Your 'explanation' is based on you just disagreeing with my 'interpretation' of Fukuda, and again cannot make sense. If anything - what you've said above confirms my interpretation.
And what this shows is that the 'diagnosis of exclusion' research criteria such as Fukuda, Oxford and Reeves (both 2003 and 2005)are confused and highly flawed in concept, and not used 'correctly' by certain researchers.
I am a Levine patient and was a subject in this study. I fit CCC. I don't know how the patients in general were selected for this study.
ReplyDeleteI'm afraid that is all hearsay. The criteria used in the NIH study are unknown. Levine uses Fukuda. Her patients were all negative in the Hanson study, Bells were the positive patients and Bell uses the Canadian criteria.
DeleteWe also do not know that you were in that study, or if you will be amongst the final results in the patient group or the control group.
Anon said "Perhaps try thinking this way. Explain how you can give a primary diagnosis of fukuda which satisfies the CCC requirements?"
ReplyDeleteRight. You can't! Not if you follow Fukuda to the letter. UNLESS you mess around with Fukuda - not following it 'properly' - and ignore the "any signs/symptoms lab findings that render selection by Fukuda void" instruction!
I can of course turn your question round and say to you "Perhaps try thinking this way. Explain how you can give a primary diagnosis of CCC which satisfies the Fukuda requirements?"
The only way you can is to answer in the way I have! The two criteria - if followed to the letter of instruction, are actually incompatible.
What has been happening is that researchers have sometimes (depending on whether they are supportive of a biomedical or psychogenic explanations of 'CFS' or ME) not been following the exclusion instructions of Fukuda. They've been including people with indication of organic dysfunction. Hence Reeves et al 2003 to 'clarify' Fukuda.
Again - remember we are talking RESEARCH cohort selection criteria here, not clinical case criteria.
This opens up a HUGE can of worms, especially for research on possible retroviral causation for ME/CFS, and particularly those attempting to 'disprove' this. The Switzer paper is a case in point.
Yes, you can and they in the study Lombardi et al. they did.
DeleteIf you follow Fukuda to the letter, which says, "Any unexplained physical examination finding or laboratory or imaging test abnormality that strongly suggests the presence of an exclusionary condition must be resolved before further classification." Then a finding must only be resolved to not be caused by an exclusionary condition. That is how a primary diagnosis of the Canadian criteria can meet the Fukuda, but not the other way around.
Obviously the patients in Lombardi et al. also had signs and symptoms not required by Fukuda, but not excluded by Fukuda.
"This opens up a HUGE can of worms, especially for research on possible retroviral causation for ME/CFS, and particularly those attempting to 'disprove' this."
Yes it does. The negative studies have failed to use the correct criteria.
We are getting into a game of semantics here - which is of course one of the major problems in CFS and ME criteria.
DeleteYour prescriptive comments here are speculative (about what Lombardi did), and this is fast turning into an argument resembling religious dogma, what 'Jesus said', and how many angels you can fit on the head of a pin.
The point is, your interpretation of what Fukuda specifies is as valid as mine! But- don't forget, vice versa also applies. This means Fukuda can be whatever the research team think it means. That's why there are so many problems. We are out of the realms of science, and into linguistics (and semantics). Fukuda is successfully used to exclude patients with neurological and other organic dysfunction by psychogenic explanations adherents, and, less successfully, used by biomedical proponents to include SOME patients who MIGHT have neurological or other dysfunction. Lombardi was different because it used the CCC. I'm willing to guess Fukuda was superfluous - possibly mentioned to keep the reviewers happy (if we are speculating about Lombardi - which, despite your convictions, we both mostly are, unless you have clear substantive evidence that the research team of Lombardi et al support your version of events!)
But I have to say - your dogmatic insistence of the 'correct' use of Fukuda is a problem. I think what we are BOTH showing here is the confusion in the criteria of exclusion (from Oxford to Fukuda, Reeves to Reeves, London, blah blah blah): and how easily multiple interpretations are made of these consensus documents, and how that (among other things) stymies scientific progress into this illness.
Anon said: "Here you can see he work was replicated for the UK study.
ReplyDelete"And so what I’m showing you here is that if we applied the techniques, that PCR I just showed you here, to a cohort of 50 patients in the UK… what I’m looking at here is patients who are similar to you, to the patients in the original study. They are largely homebound. They clearly can’t work. Many of them are homebound and bedridden, so we had an independent phlebotomist go and draw (blood from) the patients that fit the criteria, the most rigorous Canadian Consensus criteria. But we also looked at things like acute flu-like onset, and people who told us there were several in the family. "
https://www.facebook.com/note.php?note_id=10150103870586797"
Sadly, all that shows is that Fukuda may have been applied separately to the CCC for other members of the family. It does not support your claim about Lombardi et al.
Of course - nothing has been published about the UK study :(
Fukuda is not mentioned, and family members were not included. It does support my correct statement that the primary diagnosis is the Canadian criteria.
DeleteI don't disagree with that. But your claim that Fukuda was applied 'second' is not safe.
DeleteIt is because I was told it was by those involved.
DeleteTo further clarify: Proponents of psychogenic explanations for ME/CFS do their utmost to EXLCUDE, from their research cohorts, any patients who show signs/symptoms/lab findings of organic impairment. THIS is where the 'diagnosis of exclusion' criteria (Reeves 2003 and 2005, Fukuda, Oxford) come in. In Erlwein et al, the patient cohort was from previous projects (I believe the blood was stored), in which organic impairment HAD BEEN SCREENED OUT - by extensive testing!
ReplyDeleteWhat has also become evident with more recent research and and another have been doing, is that both NICE CLINICAL guidelines and Fukuda deliberately proscribe extensive CLINICAL investigations.
So, for the purposes of RESEARCH, if all but the most cursory of clinical investigations are employed as policy, logically - especially in order to (a) save money and (b) not include any patients with potential or actual organic impairment because that might scupper the psychogenic explanation you are proferring - researchers HAVE TO exclude such patients from their research cohorts. But they still might employ extensive testing on SOME patients - but only to screen them out for organic abnormality, searching for the 'pure' psychogenic cohort. I'm not saying they have been successful in that - just that this is what they are attempting (and, logically if not ethically) they should.
That doesn't mean doctors give a CLINICAL diagnosis of organic impairment of unknown origin to the patients they exclude from the research. They still appear to give psychogenic explanations, for example in the UK clinics. This is why patients are so outraged of course!
But those doctors seeking evidence of biological abnormalities are the ones who have using Fukuda 'incorrectly'. Which is a terrible shame - and why they need to start using different cohorts as a matter of urgency to build upon previous findings.
Yes, they do this. We know that. But Lombardi et al. was a not a study from the proponents of the psychogenic explanation for ME, and the experiments were not conducted by scientists who use their imaginations rather than adherence to the scientific method.
DeleteI completely agree that the other studies have been using inappropriate criteria and screening out those with organic impairment. Their methods are also not clinically validated. They have spent vast sums of money repeating these flaws, and the patients are suffering and dying whist they do this.
The criteria were applied to the letter. The scandal is having journals reject any study that would dare use only the Canadian criteria.
I don't necessarily disagree, but I think you opened a can of worms in the claims you made about Lombardi's application of Fukuda, that apply to ALL studies using Fukuda, even the 'biomedical' ones.
DeleteWhat this points to is the urgent need to use the ICC and CCC as criteria in research studies, and for the relevant researchers to get off their backsides and acknowledge the rank discrepancies in how CFS and ME criteria have been used in all research previously.
No offence intended to Dr O'Keefe, by the way, this really is an issue for the MEDICS who consider themselves specialists in diagnosis/diagnostic categories.
I only know for certain that in Lombardi et al. the CCC was the first criteria applied. The others are quotes from Mikovits. I don't have any more info on those at this time.
DeleteI think it points to the need for objective tests to define patients. These criteria problems (deliberately introduced) will cause a retrovirus to be hidden for 25 years.
Personally I don't yet back the ICC. It was rushed out and still no objective tests. At least Dr Mikovits managed to get the 6 month wait taken off.
Dr. OKeefe,
ReplyDeleteThanks for this great blogpost and for keeping an open mind on the Issue of possible HGRVs.
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