Archive for October, 2012

Message for the ME/CFS community

On June 5, 2012, an alliance of ME/CFS patient organizations and advocates sent a joint request to Secretary Sebelius of DHHS requesting that key deputies meet with us and begin to work with us to formulate a strategic, coordinated and fully-funded response to ME/CFS. We reiterated that request in a letter to Secretary Sebelius on August 8.

To date, we have been unable to secure the meeting with key deputies that we requested.  Four members of the alliance (Joan Grobstein, Jennie Spotila, Mary Dimmock and Charlotte von Salis) did meet with Dr. Nancy Lee, Deputy Assistant Secretary for Health – Women’s Health and Dr. Caira Woods, Advisor for Health and Science Policy, Office on Women’s Health.  The key points discussed in that meeting were:

  • The Ad-Hoc Workgroup (described in DHHS letters to the community and at the CFSAC) is formulating a plan focused on budget sharing and coordination across agencies. It is charged to do what it can with no additional funding. It is not charged with developing a formal strategic plan or action plan. Dr. Lee also stressed that the agencies have a great degree of autonomy, although they do collaborate with each other.
  • Given that DHHS has not agreed to the requested cross-DHHS meeting and has not committed to a cross-agency strategic, coordinated, fully-funded response, other avenues should be pursued. Dr. Lee suggested approaches that include non-profit or private sector solutions and following up with CDC and NIH separately.
  • There are tactical opportunities that could be pursued in parallel and in partnership with CFSAC that include engaging as stakeholders in the case definition process that CFSAC committed to and finding ways to improve engagement and two way dialog within the CFSAC itself.
  • We also discussed the CDC CFS Toolkit. The link to the CDC CFS Toolkit has been removed from the CFSAC website which is very good. Note that the Toolkit is still on the CDC CFS website itself. We will have to pursue that separately.

The need for a cross-DHHS strategic, coordinated, fully-funded response, developed with meaningful stakeholder input is as critical now as it ever was. However, it was clear from this meeting that we will need to use alternative approaches to make incremental progress while working toward the full objective. Besides the approaches suggested above, there are also legislative and other non-governmental options. Given our community’s limited resources, we will prioritize those activities that are most critical to both our short and long-term success.

If you have ideas on the areas that you would prioritize that you’d like to share, please share them with your organization or send them to MECFSACTION@Yahoo.com. We’ll summarize the ideas we get in and share them back with the community.

Thank you very much Charlotte, Joan, Jennie and Mary for meeting with Drs. Nancy Lee and Caira Woods.

Advertisements

Comments due November 1st!

REMINDER – The Patient Focused Drug Development Initiative is an excellent opportunity to help the FDA better understand how ME/CFS affects the patients.

Send your comments in by November 1 to ensure that the FDA understands why ME/CFS should be selected as one of the 20 diseases. A sample letter has been provided in case you want to pull from it to develop your own. As you write your own letter, make points that reflect how ME/CFS meets the criteria above.

Comments should be submitted electronically at

http://www.regulations.gov/

FDA-2012-N-0967

http://www.regulations.gov/#!docketDetail;D=FDA-2012-N-0967

Written comments can be submitted to the Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852. Make sure you include the docket number (FDA-2012-N-0967).

Further information on the patient focused drug development initiative and the list of 39 diseases initially nominated can be found here: https://www.federalregister.gov/articles/2012/09/24/2012-23454/prescription-drug-user-fee-act-patient-focused-drug-development-public-meeting-and-request-for

1. Sample Letter

  • Note that the letters are limited to 2000 characters so you may need to remove some of the sample text provided to allow additional space for your personal story.
  • If you are sending in comments by regular mail, include the’To’, the ‘From’ and the ‘Docket number’. These are not necessary if sending in electronically.
  • If you are sending in electronically, select ‘Individual Consumer’ for the ‘Category’ and ‘None’ for ‘Organization’ if no other choice is appropriate

To: FDA Patient Focused Drug Development Initiative

From: <include your name here>

Docket Number: FDA-2012-N-0967

I am writing to request that chronic fatigue syndrome (also called myalgic encephalomyelitis or ME/CFS in the U.S.) be included as one of the 20 diseases in the patient focused drug development initiative.

ME/CFS is a complex, neuroimmune disease that affects one million Americans of all ages, races and income levels. According to the CDC, ME/CFS can be as debilitating as Multiple Sclerosis (MS), end-stage renal disease, chronic obstructive pulmonary disease (COPD) and similar chronic conditions. Patients can be sick for decades, with 25% house, bed or wheelchair bound. While some patients work part time or rest all weekend to keep going in their jobs, others struggle to take care of themselves, let alone take care of their families or work. One study suggests patients can die prematurely from cancer, heart disease and suicide.

And yet, tragically, in the almost thirty years since the outbreaks that brought ME/CFS to national attention, there are NO approved drugs, NO agreement on biomarkers or outcome measures and there have been almost no clinical trials for drugs to treat the disease course of ME/CFS. Patients have been abandoned with no relief from the devastation of ME/CFS.

<Include personal story here – make points that speak to one of the criteria – e.g. how this has affected you functionally, symptomatically (e.g. cognitive impact, pain), or how it has affected your daily activities, how this has affected your child with ME/CFS, the lack of therapy or your inability to access cause they are not approved for ME/CFS.

By ensuring a thorough understanding of the severity of ME/CFS from a patient perspective, especially given the lack of any treatments to change the course of the disease, the patient focused drug development initiative could make a tremendous difference in the lives of one million Americans.

2. Additional information

FDA Disease Area Selection Criteria and How ME/CFS Meets These Criteria

This table is intended to help you as you are writing your letter by providing additional information about how ME/CFS meets the FDA criteria for selection of disease areas. Try to include points in your letter that hit on these key criteria.

FDA Criteria How ME/CFS meets that criteria – examples as food for thought
Disease areas that are chronic, symptomatic, or affect functioning and activities of daily living;
  • Chronic, sick for decades, low percentage of patients improve
  • 25% bedbound or homebound, unable to work. Patients who do work may work part time and/or are underemployed. Relapsing course means little predictability. Impact of disease on patient’s life is so great that suicide risk increased
Disease areas that reflect a range of severity;
  • Wide range of severity – some patients work a 40 hour week and compensate by sleeping weekends but many patients can not work at all. The most serious patients are unable to do little more than the most basic activities of personal care
Disease areas for which aspects of the disease are not formally captured in clinical trials;
  • There is only one drug in clinical trials and its been there since 1997
  • There are a few INDs but most are focused on nutriceuticals. There have been studies into psychological treatments
Disease areas that have a severe impact on identifiable subpopulations (such as children or the elderly);
  • Severe impact on children because they are unable to attend school or graduate. Even if they get better, they have missed on significant life lessons
Disease areas that represent a broad range in terms of size of the affected population
  • Estimated that 1 million are affects – women and men, all economic levels, all ethnic groups
Disease areas for which there are currently no therapies or very few therapies, or the available therapies do not directly affect how a patient feels, functions, or survives.
  • No approved therapies, only limited symptom relief

Letters can be from patients, family members, friends….. and from any country as well!

Please help make sure that ME/CFS is one of the 20 diseases selected.

(During the FDA meeting on Oct 25th 2012, FDA officials said that it will take them a couple of months to determine which diseases will be selected.)

 

 

 

CALL TO ACTION

Summary of the Patient Focused Drug Development Initiative

What is it: As part of its commitment under the recently approved Prescription Drug User Fee Act (PDUFA V), the FDA will be conducting an initiative, called the patient-focused drug development initiative, to provide for a more systematic approach to obtain the patient’s perspective on the disease severity and the currently available treatments. The intent is to ensure a thorough understanding of the severity of the treated condition and the adequacy of the existing treatment options.

This initiative will be conducted for each of 20 different disease areas over a period of 5 years. The FDA has nominated an initial list of 39 diseases, including ME/CFS, using the following criteria:

  • Disease areas that are chronic, symptomatic, or affect functioning and activities of daily living;
  • Disease areas that reflect a range of severity;
  • Disease areas for which aspects of the disease are not formally captured in clinical trials;
  • Disease areas that have a severe impact on identifiable subpopulations (such as children or the elderly);
  • Disease areas that represent a broad range in terms of size of the affected population
  • Disease areas for which there are currently no therapies or very few therapies, or the available therapies do not directly affect how a patient feels, functions, or survives.

The next step in the process is for the FDA to gather public input between now and November 1st on which of disease areas should be selected for inclusion in this initiative. Additional disease areas may also be nominated during this time.

Note that initiative is in addition to the ME/CFS FDA stakeholder meeting that Dr. Woodcock, Director of the Center for Drug Evaluation and Research at the FDA, has already committed to.

How can you help: For ME/CFS, this is an excellent opportunity to help the FDA better understand how ME/CFS affects the patients. Your support is essential to ensure that ME/CFS is one of the 20 selected diseases.

Please send your comments in by November 1 to ensure that the FDA understands why ME/CFS should be selected as one of the 20 diseases. A sample letter has been provided in case you want to pull from it to develop your own. As you write your own letter, make points that reflect how ME/CFS meets the criteria above.

Comments should be submitted electronically at

http://www.regulations.gov/

FDA-2012-N-0967

http://www.regulations.gov/#!docketDetail;D=FDA-2012-N-0967

Written comments can be submitted to the Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852. Make sure you include the docket number (FDA-2012-N-0967).

Further information on the patient focused drug development initiative and the list of 39 diseases initially nominated can be found here: https://www.federalregister.gov/articles/2012/09/24/2012-23454/prescription-drug-user-fee-act-patient-focused-drug-development-public-meeting-and-request-for

1. Sample Letter

  • Note that the letters are limited to 2000 characters so you may need to remove some of the sample text provided to allow additional space for your personal story.
  • If you are sending in comments by regular mail, include the’To’, the ‘From’ and the ‘Docket number’. These are not necessary if sending in electronically.
  • If you are sending in electronically, select ‘Individual Consumer’ for the ‘Category’ and ‘None’ for ‘Organization’ if no other choice is appropriate

To: FDA Patient Focused Drug Development Initiative

From: <include your name here>

Docket Number: FDA-2012-N-0967

I am writing to request that chronic fatigue syndrome (also called myalgic encephalomyelitis or ME/CFS in the U.S.) be included as one of the 20 diseases in the patient focused drug development initiative.

ME/CFS is a complex, neuroimmune disease that affects one million Americans of all ages, races and income levels. According to the CDC, ME/CFS can be as debilitating as Multiple Sclerosis (MS), end-stage renal disease, chronic obstructive pulmonary disease (COPD) and similar chronic conditions. Patients can be sick for decades, with 25% house, bed or wheelchair bound. While some patients work part time or rest all weekend to keep going in their jobs, others struggle to take care of themselves, let alone take care of their families or work. One study suggests patients can die prematurely from cancer, heart disease and suicide.

And yet, tragically, in the almost thirty years since the outbreaks that brought ME/CFS to national attention, there are NO approved drugs, NO agreement on biomarkers or outcome measures and there have been almost no clinical trials for drugs to treat the disease course of ME/CFS. Patients have been abandoned with no relief from the devastation of ME/CFS.

<Include personal story here – make points that speak to one of the criteria – e.g. how this has affected you functionally, symptomatically (e.g. cognitive impact, pain), or how it has affected your daily activities, how this has affected your child with ME/CFS, the lack of therapy or your inability to access cause they are not approved for ME/CFS.

By ensuring a thorough understanding of the severity of ME/CFS from a patient perspective, especially given the lack of any treatments to change the course of the disease, the patient focused drug development initiative could make a tremendous difference in the lives of one million Americans.

2. Additional information

FDA Disease Area Selection Criteria and How ME/CFS Meets These Criteria

This table is intended to help you as you are writing your letter by providing additional information about how ME/CFS meets the FDA criteria for selection of disease areas. Try to include points in your letter that hit on these key criteria.

FDA Criteria How ME/CFS meets that criteria – examples as food for thought
Disease areas that are chronic, symptomatic, or affect functioning and activities of daily living;
  • Chronic, sick for decades, low percentage of patients improve
  • 25% bedbound or homebound, unable to work. Patients who do work may work part time and/or are underemployed. Relapsing course means little predictability. Impact of disease on patient’s life is so great that suicide risk increased
Disease areas that reflect a range of severity;
  • Wide range of severity – some patients work a 40 hour week and compensate by sleeping weekends but many patients can not work at all. The most serious patients are unable to do little more than the most basic activities of personal care
Disease areas for which aspects of the disease are not formally captured in clinical trials;
  • There is only one drug in clinical trials and its been there since 1997
  • There are a few INDs but most are focused on nutriceuticals. There have been studies into psychological treatments
Disease areas that have a severe impact on identifiable subpopulations (such as children or the elderly);
  • Severe impact on children because they are unable to attend school or graduate. Even if they get better, they have missed on significant life lessons
Disease areas that represent a broad range in terms of size of the affected population
  • Estimated that 1 million are affects – women and men, all economic levels, all ethnic groups
Disease areas for which there are currently no therapies or very few therapies, or the available therapies do not directly affect how a patient feels, functions, or survives.
  • No approved therapies, only limited symptom relief

Letters can be from patients, family members, friends….. and from any country as well!

Please help us make sure that ME/CFS is one of the 20 diseases selected.

CDC’s insistence on retaining and promulgating misinformation (!) harms patients!

Once again we urge you to read a post at the OccupyCFS blog.

http://www.occupycfs.com/2012/10/17/this-is-why/

CDC needs to understand its role in promulgating misinformation about CFS and they need to STOP doing so.

Mark your calendar

 

As part of the activities that the FDA is undertaking with the ME/CFS community, they will be hosting a webinar

Excellence in Advocacy Webinar – November 15, 2012 (2pm-3pm EST)

 

http://www.fda.gov/Drugs/NewsEvents/ucm319188.htm

 

Hopefully more details will be available soon.

October 2012 CFSAC videos

(Sorry if these are not in order…. the last link is to a page that has all of the videos)

 

http://www.youtube.com/watch?v=4Zl2RX4URuI&feature=plcp Welcome & Opening Remarks (CFSAC Fall 2012)

http://www.youtube.com/watch?v=01hZYq4GMtI&feature=plcp Biomarkers – An Overview & Future Look (CFSAC Fall 2012)

http://www.youtube.com/watch?v=oIGpfvfFZ1w&feature=relmfu Public Comment on Day One – AM (CFSAC Fall 2012)

http://www.youtube.com/watch?v=buDxhejdg90&feature=plcp Agency Updates from HRSA, NIH, and FDA (CFSAC Fall 2012)

http://www.youtube.com/watch?v=IGASSh7YV3s&feature=plcp FDA & Drug Development (CFSAC Fall 2012)

http://www.youtube.com/watch?v=_fIEeQBdvxM&feature=plcp Public Comment on Day One – PM (CFSAC Fall 2012)

http://www.youtube.com/watch?v=Fs1A6KhHInU&feature=relmfu Committee Discussion & Plans for Day Two (CFSAC Fall 2012)

http://www.youtube.com/watch?v=PWBmqd8LDhg&feature=plcp Opening Remarks & Agency Updates (CFSAC Fall 2012)

http://www.youtube.com/watch?v=af_r5LiIjXQ&feature=relmfu Social Security Administration (CFSAC Fall 2012)

http://www.youtube.com/watch?v=qGb0U6EaI4o&feature=relmfu Public Comment on Day Two (CFSAC Fall 2012)

http://www.youtube.com/watch?v=MTHpny0u-XU&feature=relmfu ME/CFS Organizations (CFSAC Fall 2012)

http://www.youtube.com/watch?v=NFaXiiSdZqI&feature=relmfu A Path Forward (CFSAC Fall 2012)

http://www.youtube.com/watch?v=CO9bO-udcY0&feature=relmfu Finalize Recommendations (CFSAC Fall 2012)

http://www.youtube.com/user/USGOVHHS/videos?query=CFSAC Search results for “CFSAC”:

 

 

 

The public comment presented at the CFSAC meeting October 3 and 4, 2012 was strong, and some excellent points were made (some of them over and over again). Federal funding for ME/CFS research is pitifully small and the public comment by Ms. Janelle Wiley provided some interesting comparisons.

Ms. Wiley (who provided her comment by phone) has kindly given permission to share her public comment here:

“Hi, I cannot travel to speak to you in person but it’s Good to be with you by phone; thanks for your attention to ME/CFS. One thing that strikes me when listening to CFSAC meetings is that there is never any encouragement for any funding.

There is no reason under the sun why ME/CFS is not being funded like any other disease. Yes, I get that there is a budget crisis and we need to spend less on the national budget. But the amount being spent on our disease or disease spectrum–6 million dollars in a good year–is easily available to many state budgets. North Carolina spends 10 million on aquariums. The city of Glendale, Arizona, spent 23 million in outside counsel over 5 years, which is 4 million per year (we get that amount some years). California spend almost 45 million on new vehicles and almost 30 million on new furniture. New York is spending 50 million dollars on ads promoting its business policy. These aren’t necessarily bad projects; point is that our budget or even 5 times more is well within the reach of a much smaller body right now in this current economy.

It is shameful that ME/CFS is basically not being funded.

Whatever model it is we are using to fund research, it should be applied to ME/CFS the same as to Lupus and cancer and Alzheimer’s, taking into consideration the burden and incidence of the disease.

I do not know what the hangup is, but it is not the sad state of the national budget. That’s just an excuse. Whatever the problem really is, please fix it. This is a very serious disease which isn’t being handled seriously at all. I don’t think the problem is in this room, but please talk to your uplines. Thanks.

In using funds to do studies, there are two main things that need to be addressed. One is the SEP panel. Typically it is staffed with mostly people who are mostly interested in psychogenic theories. These theories are not scientific—e.g. cannot be proven and do not consider alternate hypotheses or accept disproof—and have not yielded any useful ideas: they did not for Parkinson’s disease or multiple sclerosis, and they are not for fibromyalgia, TMJ, or ME/CFS. It is past time to consciously change the bias from the psychogenic to the biomedical.

The second is the definition. There has been a lot of talk about lumping and splitting. Both are appropriate methods of approaching a problem—to a point. But there is a point at which lumping becomes absurd. When you are no longer lumping “people who are similar to ME/CFS” together and you’re gathering “people whose doctors or researchers have not (or have not bothered to) figure out what’s actually wrong with them”, you’ve gotten to the absurd point.

There are multiple inclusion criteria for CFS or ME/CFS being used. It’s well known that the Oxford inclusion contains large numbers of people who can be diagnosed with other conditions. A Newcastle study demonstrates this. David Tuller wrote about it in the New York Times. We wrote about it in ME Analysis. It’s been mentioned here at CFSAC a lot. The Oxford inclusion identifies people who have longlasting fatigue of definite onset without requiring other symptoms. CDC says this is “idiopathic chronic fatigue” and not CFS. Yet the CDC, like most everyone else, makes heavy use of Oxford studies to decide what to do with ME and CFS patients. This is not science. It’s kind of, quackish. Many articles in the literature call attention to problems with this.

The “Empiric” surveys which are used by CDC to attempt to operationalize the Fukuda criteria select—almost entirely—people who do not have ME/CFS. This approach to inclusion has been rejected by CFSAC, by the international symposium at Bond University, and by patient advocates around the world. And in the literature. The problem with this approach is that it allows feeling depressed or sad to substitute for debility and fatigue. Those are not actually the same thing. It’s no wonder CDC’s webpage claims it’s difficult to distinguish between depression and CFS! They looked for depression under the title of CFS, and found depression, which they label CFS. Funny how that works.

Also, education. CDC is very proud of themselves that they have educated a lot of people. What they may not realize is that, partly because of the uncorrected problems with inclusion criteria, CDC’s information is very wrong in many particulars. Despite the urgent need for physicians to know about this condition, I, like many others, am actually appalled that multiple health care providers have seen CDC’s education. Misinformation is actually worse than no information. The IACFS/ME’s Primer is a useful document which exists now.

So in summary, what we need is funding—and this is attainable—and we need to use it wisely. Quit relying on the psychogenic model, and instead rely on a model that produces solutions: biomedicine.

Thank you”

 

References:

 

  1. Newton JL, Mabillard H, Scott A, Hoad A, Spickett G. The Newcastle NHS Chronic Fatigue Syndrome Service: not all fatigue is the same. J R Coll Physicians Edinb. 2010 Dec;40(4):304-7.
  2. http://www.nytimes.com/2011/03/08/health/research/08fatigue.html and author reply to White et al. http://www.nytimes.com/2011/03/15/health/15letters-STUDYINGAFAT_LETTERS.html?ref=research (see all of Tuller’s articles http://www.research1st.com/2011/12/08/tuller-tells-it-like-it-is/ and an interview with him http://www.theopennotebook.com/2012/01/18/david-tuller-cfs/ )
  3. http://evaluatingpace.phoenixrising.me/homepageanim.html
  4. Bond university. International Science Symposium for Myalgic Encephalomyelitis and Chronic Fatigue Syndrome (ME/ CFS). 02-04 December 2010. http://www.bond.edu.au/research/research-at-bond/events/BD3_014159
  5. Jason LA, Helgerson J, Torres-Harding SR, Carrico AW, Taylor RR. Variability in diagnostic criteria for chronic fatigue syndrome may result in substantial differences in patterns of symptoms and disability. Eval Health Prof. 2003 Mar;26(1):3-22.
  6. Merz S. [Chronic fatigue syndrome. More and more differential diagnoses suggest a new view of this syndrome]. [Article in Swedish] Lakartidningen. 2002 Aug 22;99(34):3282-7. Abstract.
  7. Jason LA, Evans M, Brown A, Brown M, Porter N, et al. “Sensitivity and Specificity of the CDC Empirical Chronic Fatigue Syndrome Case Definition.” Psych. 2010 Apr; 1(1):9-16.
  8. Carruthers, B. M., et al. (2011), Myalgic encephalomyelitis: International Consensus Criteria. Journal of Internal Medicine, 270: 327–338. doi: 10.1111/j.1365-2796.2011.02428.x
  9. Carruthers, et al. “Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols.” J CFS 2003. 11(1) http://www.co-cure.org/ccpccd.pdf
  10. Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med. 1994 Dec 15;121(12):953-9.
  11. Reeves WC, Lloyd A, Vernon SD, Klimas N, Jason LA, Bleijenberg G, Evengard B, White PD, Nisenbaum R, Unger ER; International Chronic Fatigue Syndrome Study Group. Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution. BMC Health Serv Res. 2003 Dec 31;3(1):25. Review.
  12. Sharpe MC, Archard LC, Banatvala JE, Borysiewicz LK, Clare AW, David A, Edwards RH, Hawton KE, Lambert HP, Lane RJ, et al. A report–chronic fatigue syndrome: guidelines for research. J R Soc Med. 1991 Feb;84(2):118-21. Department of Psychiatry, University of Oxford.
  13. Reeves WC, Wagner D, Nisenbaum R, Jones JF, Gurbaxani B, Solomon L, Papanicolaou DA, Unger ER, Vernon SD, Heim C. Chronic fatigue syndrome–a clinically empirical approach to its definition and study. BMC Med. 2005 Dec 15;3:19.
  14. Holmes GP, Kaplan JE, Gantz NM, Komaroff AL, Schonberger LB, Straus SE, Jones JF, Dubois RE, Cunningham-Rundles C, Pahwa S, et al. Chronic fatigue syndrome: a working case definition. Ann Intern Med. 1988 Mar;108(3):387-9.
  15. A M Ramsay, E G Dowsett, J V Dadswell, W H Lyle, and J G Parish. Icelandic disease (benign myalgic encephalomyelitis or Royal Free disease). Br Med J. 1977 May 21; 1(6072): 1350.
  16. Maes M, Twisk FN. “Chronic fatigue syndrome: Harvey and Wessely’s (bio)psychosocial model versus a bio(psychosocial) model based on inflammatory and oxidative and nitrosative stress pathways.” BMC Med. 2010 Jun 15;8:35. PMID: 20550693
  17. http://www.nccivitas.org/2009/300-million-wasteful-and-frivolous-spending-included-fy-2009/;
  18. http://www.controllinglegalcosts.com/2011/09/15/iowa-spends-over-6-million-in-outside-counsel-fees-over-five-years/
  19. http://www.wjhg.com/news/headlines/Florida-Spends-50-Million-on-Gasoline–169217196.html
  20. http://www.sdgln.com/news/2010/02/10/california-budget-crisis-diaries-state-spends-75-million-furnishings-and-more
  21. http://wyrk.com/new-york-state-spends-big-bucks-for-new-business-campaign/

     

     

    Thank you to everyone who participated (in any way shape or form) in the October 2012 CFSAC meeting!