Posts Tagged 'OccupyCFS'

Confusion at NIH

Quote from “P2P and Dr. Francis Collins”

“Ok, let’s pause for a minute. NIH is co-sponsoring the IOM study under their contract with the National Academy. The IOM contract had been controversial for months, and Dr. Maier was scheduled to speak at the IOM meeting in just three weeks. Yet the Deputy Director of NIH had no idea what is going on with it, Dr. Collins needed an explanation of the difference between IOM and P2P, and now Dr. Murray had to scramble to figure out if there was a third meeting he was not aware of. “

Would a trail of breadcrumbs help them?

The full post is well worth reading:

P2P draft agenda is now available

Good grief!

Does P2P actually stand for “Purpose: to Prevent” meaningful research?

Given important portions of the draft agenda (and those presenting those portions), one might not be mistaken for thinking so….

For instance,

The second main topic of the Workshop is titled: “Given the unique challenges of ME/CFS, how can we foster innovative research to enhance the development of treatments for patients?”

The three speakers for this section are Dr. Dedra Buchwald, Dr. Dan Clauw, and Dr. Niloofar Afari. If anyone thought that psychosocial theories and functional somatic syndromes would not make an appearance at the Workshop, I’m afraid I must correct your false workshop belief. “

read the full post at OccupyCFS (here: )

link for draft agenda:

P2P: The Question They Will Not Ask — reposted with permission from OccupyCFS

Mary Dimmock and Jennie Spotila have written a very important post about a big problem with P2P. With their permission it is being reposted here in its entirety. (Thank you Mary and Jennie.)


P2P: The Question They Will Not Ask

July 21st, 2014 Jennie Spotila Leave a comment Go to comments

by Mary Dimmock and Jennie Spotila

cornerstone-contentThe most important question about ME/CFS – the question that is the cornerstone for every aspect of ME/CFS science – is the question that the P2P Workshop will not ask:

How do ME and CFS differ? Do these illnesses lie along the same continuum of severity or are they entirely separate with common symptoms? What makes them different, what makes them the same? What is lacking in each case definition – do the non-overlapping elements of each case definition identify a subset of the illness or do they encompass the entirety of the population?

Boiled down to its essence, this set of questions is asking whether all the “ME/CFS” definitions represent the same disease or set of related diseases. The failure to ask this question puts the entire effort at risk.

This fundamental question was posed in the 2012 application for the Office of Disease Prevention to hold the P2P meeting (which I obtained through FOIA). It was posed in the 2013 contract between AHRQ and the Oregon Health & Science University for the systematic evidence review (which I obtained through FOIA). It was posed to the P2P Working Group at its January 2014 meeting to refine the questions for the evidence review and Workshop (according to Dr. Susan Maier at the January 2014 Institute of Medicine meeting).

And then the question disappeared.

The systematic evidence review protocol does not include it. Dr. Beth Collins-Sharp said at the June 2014 CFSAC meeting that the Evidence Practice Center is not considering the question because there is “not enough evidence” in the literature to answer the question. However, she said that the P2P Workshop could still consider the question.

But the draft agenda for the Workshop does not include it. Furthermore, every aspect of the P2P Workshop treats “ME/CFS” as a single disease:

  • The P2P description of ME/CFS refers to it as a single disorder or illness throughout the meeting webpage.

  • The P2P website characterizes the names myalgic encephalomyelitis and chronic fatigue syndrome as synonymous.

  • Every section of the Workshop agenda lumps all the populations described by the multiple case definitions together, discussing prevalence, tools, subsets, outcomes, presentation, and diagnosis of this single entity.

A 20 minute presentation on “Case Definition Perspective” is the only lip service paid to this critical issue. This is completely inadequate, if for no other reason than because the presentation is isolated from discussions on the Workshop Key Questions and dependent topics like prevalence and natural history. As a result, it is unlikely to be thoroughly discussed unless one of the Panelists has a particular interest in it.

Why is this problematic? Because both the P2P Workshop and the evidence review are based on the assumption that the full set of “ME/CFS” case definitions describe the same disease. This assumption has been made without proof that it is correct and in the face of data that indicate otherwise, and therein lies the danger of failing to ask the question.

What if the case definitions do not actually describe a single disease? If there are disparate conditions like depression, deconditioning, non-specific chronic fatigue and a neuroimmune disease characterized by PEM encompassed by the full set of “ME/CFS” definitions, then lumping those together as one entity would be unscientific.

The most important part of designing scientific studies is to properly define the study subjects. One would not combine liver cancer and breast cancer patients into a single cohort to investigate cancer pathogenesis. The combination of those two groups would confound the results; such a study would be meaningful only if the two groups were separately defined and then compared to one another to identify similarities or differences. The same is true of the P2P evidence review of diagnostics and treatments: assuming that all “ME/CFS” definitions capture the same disease (or even a set of biologically related diseases) and attempting to compare studies on the combined patients will yield meaningless and confounded results if those definitions actually encompass disparate diseases.

There is a growing body of evidence that underscores the need to ask the fundamental question of whether “ME/CFS” definitions represent the same disease:

  • The P2P Workshop is focused on “extreme fatigue” as the defining characteristic of “ME/CFS,” but fatigue is a common but ill-defined symptom across many diseases. Further, not all “ME/CFS” definitions require fatigue or define it in the same way. For instance, Oxford requires subjective fatigue, and specifically excludes patients with a physiological explanation for their fatigue. But the ME-ICC does not require fatigue; instead it requires PENE, which is defined to have a physiological basis.

  • When FDA asked CFS and ME patients to describe their disease, we did not say “fatigue.” Patients told FDA that post-exertional malaise was the most significant symptom: “complete exhaustion, inability to get out of bed to eat, intense physical pain (including muscle soreness), incoherency, blacking out and memory loss, and flu-like symptoms.”

  • Multiple studies by Jason, Brenu, Johnston and others have demonstrated significant differences in disease severity, functional impairment, levels of immunological markers and patient-reported symptoms among the different case definitions.

  • Multiple studies have demonstrated that patients with PEM have impairment in energy metabolism and lowered anaerobic threshold, and have shown that patients with depression, deconditioning and a number of other chronic illnesses do not have this kind of impairment.

  • Multiple studies have demonstrated differences in exercise-induced gene expression between Fukuda/CCC patients and both healthy and disease control groups.

  • The wide variance in prevalence estimates shines a light on the case definition problem. Prevalence estimates for Oxford and Empirical populations are roughly six times higher than the most commonly accepted estimate for Fukuda. Even Fukuda prevalence estimates vary widely, from 0.07% to 2.6%, underscoring the non-specificity of the criteria. Nacul, et al., found that the prevalence using CCC was only 58% of the Fukuda prevalence. Vincent, et al., reported that 36% of Fukuda patients had PEM, representing a smaller population that would be eligible for diagnosis under CCC.

  • The work of Dr. Jason highlights the danger of definitions that include patients with primary psychiatric illnesses, especially because such patients may respond very differently to treatments like CBT and GET.

By contrast, there have not been any published studies that demonstrate that the set of “ME/CFS” definitions being examined in P2P encompass a single entity or biologically related set of entities. From Oxford to Fukuda to ME-ICC, there are significant differences in the inclusion and exclusion criteria, including differences in the exclusion of primary psychiatric illness. The magnitude of these differences makes the lack of such proof problematic.

Given that treating all “ME/CFS” definitions as a single entity is based on an unproven assumption of the clinical equivalence of these definitions, and given that there is ample proof that these definitions do not represent the same disease or patient population, it is essential that the P2P “ME/CFS” study start by asking this question:

Does the set of “ME/CFS” definitions encompass the same disease, a spectrum of diseases, or separate, discrete conditions and diseases?

The failure to tackle this cornerstone question up-front in both the agenda and the evidence review puts the scientific validity of the entire P2P Workshop at risk. If this question is not explicitly posed, then the non-ME/CFS expert P2P Panel will swallow the assumption of a single disorder without question, if for no other reason than that they do not know the literature well enough to recognize that it is an assumption and not established fact.

Serious concerns!

Ms. Jennie Spotila has given permission to repost her assessment of the P2P study protocol here in its entirety. (Thank you Ms. Spotila.)

Please post comments on her blog

As concerned as we are about IOM, P2P looks far, far worse!

Protocol for Disaster?

May 2nd, 2014 Jennie Spotila Leave a comment Go to comments

disasterThe study protocol for the systematic review of ME/CFS was posted by the Agency for Healthcare and Research Quality yesterday. It’s a recipe for disaster on its own, and within the broader context of the NIH P2P Workshop it’s even worse. Let me show you some of the reasons why.

Remind Me What This Is

The systematic evidence review is the cornerstone of the P2P process. The P2P meeting on ME/CFS will feature a panel of non-ME/CFS experts who will produce a set of recommendations on diagnosis, treatment, and research.

Because the P2P Panel members are not ME/CFS experts, they need background information to do their job. This systematic evidence review done by the Oregon Health & Science University under contract to AHRQ will be that background information. The systematic evidence report will be presented to the Panel in advance of the public P2P meeting, and will be used to establish the structure of the meeting as well.

The systematic review is the foundation. If done correctly, it would be a strong basis for a meaningful workshop. If done poorly, then everything that follows – the workshop and the resulting recommendations – will crumble. Based on the protocol published yesterday, I think “crumble” is putting it mildly.

The Key Questions

You can’t get the right answer if you don’t ask the right questions. (Dr. Beth Collins-Sharp, CFSAC Minutes, May 23, 2013, p. 12)

As I wrote in January, the original draft questions for the evidence review included whether CFS and ME were separate diseases. That question is GONE, my friends. Now the review is only looking at two things:

  • What methods are available to clinicians to diagnose ME/CFS and how do the use of these methods vary by patient subgroups?

  • What are the benefits and harms of therapeutic interventions for patients with ME/CFS and how do they vary by patient subgroups?

These questions are based upon a single and critical assumption: ME and CFS are the same disease. Differences among patient groups represent subtypes, not separate diseases. The first and most important question is whether the ME and CFS case definitions all describe one disease. But they’re not asking that question; they have already decided the answer is yes.

The study protocol and other communications from HHS (including today’s CFSAC listserv message) state that the P2P Working Group refined these study questions. The implication is that since ME/CFS experts and one patient served on the Working Group, we should be satisfied that these questions were appropriately refined. But what I’m piecing together from various sources indicates that the Working Group did not sign off on these questions as stated in the protocol.

Regardless of who drafted these questions, they cannot lead to the right answers because they are not the right questions. And when you examine the protocol of how the evidence review will be conducted, these questions get even worse.

Protocol Problems

The real danger signals come from the description of how this evidence review will be done. The issue is what research will be included and assessed in the review. For example, when asking about diagnostic methods, what definitions will be considered?

This evidence review will include studies using “Fukada [sic], Canadian, International, and others“, and the Oxford definition is listed in the table of definitions on page 2 of the protocol. That’s right, the Oxford definition. Oxford requires only one thing for a CFS diagnosis: six months of fatigue. So studies done on people with long-lasting fatigue are potentially eligible for inclusion in this review.

The description of the population to be covered in the review makes that abundantly clear. For the key question on diagnostic methods, the study population will be: “Symptomatic adults (aged 18 years or older) with fatigue.” There’s not even a time limit there. Three months fatigue? Four? Six? Presence of other symptoms? Nope, fatigue is enough.

There is a specific exclusion: “Patients with other underlying diagnosis,” but which conditions are exclusionary is not specified. So will they exclude studies of patients with depression? Because the Oxford definition does not exclude people with depression and anxiety. We’ve seen this language about excluding people with other underlying diagnosis before – and it results in lumping everyone with medically “unexplained” fatigue into one group. This protocol is set up to result in exactly that. It erases the lines between people with idiopathic chronic fatigue and people with ME, and it puts us all in the same bucket for analysis.

And what about the key question on treatment? What studies will be included there? All of them. CBT, GET, complementary/alternative medicine, and symptom-based medication management. It’s not even restricted to placebo trials; trials with no treatment, usual care, and head-to-head trials are all included.

Let’s do the math. Anyone with unexplained fatigue, diagnosed using Oxford or any other definition, and any form of treatment. This adds up to the PACE trial, and studies like that.

But it’s even worse. The review will look at studies published since January 1988 because that was the year “the first set of clinical criteria defining CFS were published.” (page 6) Again, let’s do the math: everything published on ME prior to 1988 will be excluded.

Finally, notice the stated focus of the review: “This report focuses on the clinical outcomes surrounding the attributes of fatigue, especially post-exertional malaise and persistent fatigue, and its impact on overall function and quality of life because these are unifying features of ME/CFS that impact patients.” (page 2) In other words, PEM = fatigue. And fatigue is a unifying concept in ME/CFS. Did anyone involved in drafting this protocol actually listen to anything we said at last year’s FDA meeting?

Bad Science

Credit: ElodieUnderGlass

Maybe you’re thinking it’s better for this review to cast a broad net. Capture as much science as possible and then examine it to answer the key questions. But that’s not going to help us in this case.

This review will include Oxford studies. It will take studies that only require patients to have fatigue and consider them as equivalent to studies that require PEM (or even just fatigue plus other symptoms). In other words, the review will include studies like PACE, and compare them to studies like the rituximab and antiviral trials, as if both patient cohorts were the same.

That assumption – that patients with fatigue are the same as patients with PEM and cognitive dysfunction – is where this whole thing falls apart. That assumption contaminates the entire evidence base of the study.

In fact, this review protocol makes an assumption about how the Institute of Medicine study will answer the same question. It is possible (though not assured) that IOM will design diagnostic criteria for the disease characterized by PEM and cognitive dysfunction. But this evidence review is based on an entirely different patient population that includes people with just fatigue. The conclusions of this evidence review may or may not apply to the population defined by the IOM. It’s ridiculous!

But it’s the end use that really scares me. Remember that this systematic evidence review report will be provided to that P2P Panel of non-ME/CFS experts. The Panel will not be familiar with the ME/CFS literature before they get this review. And the review will conflate all these definitions and patient populations together as if they are equivalent. I think it’s obvious what conclusion the P2P Panel is likely to draw from this report.

I would love to be wrong about this. I would love for someone to show me how this protocol will result in GOOD science, and how it will give the P2P Panel the right background and foundation for the recommendations they will draft. Please, scientists and policy makers who read this blog – can you show me how this protocol will produce good science? Because I am just not seeing it.

What Do We Do?

This protocol is bad news but it is by no means the last word. Plans are already in motion for how the advocacy community can respond. I will keep you posted as those plans are finalized.

Make no mistake, this evidence review and P2P process are worse than the IOM study. We must respond. We must insist on good science. We must insist that our disease be appropriately defined and studied.

Info on IOM Panelists

Info on IOM Panelists

As of today we have 16 days (til 23 December 2013) to submit comment on the IOM panelists.

To give everyone info that may help substantiate comment, info on the “unknown” panelists was posted 2 days ago and today info on the “knowns” has been posted on OccupyCFS blog.

“IOM Panelists: The Knowns

December 7th, 2013 Jennie Spotila Leave a comment Go to comments

In this post, we present profiles of the eight members of the Institute of Medicine ME/CFS definition panel who are known to the ME/CFS community in some capacity. Many, but not all, of them are ME/CFS experts in that they work predominantly in that area. You can read about the team who put these profiles together and the methods we used in this previous post.

Important disclaimer: Many of us know one or more of these panelists quite well. They are our doctors, our colleagues, our friends. We strove to be as objective as possible, and applied all the same research methods and questions here as we did for the other panelists.   ….”

Links to previous OccupyCFS posts on this:

No way to guess how this will turn out…..

You probably remember that one of the October 2012 CFSAC recommendations was

CFSAC recommends that you will promptly convene (by 12/31/12 or as soon as possible thereafter) at least one stakeholders’ (Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS)experts, patients, advocates) workshop  in consultation with CFSAC members to reach a consensus for a case definition useful for research, diagnosis and treatment of ME/CFS beginning with the 2003 Canadian Consensus  Definition for discussion purposes.”

We know that CDC has a definition initiative as part of its multi-site study, and we know that NIH and AHRQ have said they were conducting a research case definition process.

In his letter to the CFSAC on May 1, 2013 Dr. Howard Koh (Assistant Secretary of Health at the Department of Health and Human Services - DHHS) wrote:

The National Institutes of Health (NIH) is convening an Evidence-based Methodology Workshop process  . . . to address the issue of case definitions appropriate for ME/CFS research. However, it will not cover in detail a clinical case definition. The Office of the Assistant Secretary for Health, Department of Health and Human Services, is actively pursuing options for a separate effort that would work in coordination with the NIH process, but result in a case definition useful for clinicians who see patients with symptoms that may be ME/CFS. . . . .” ( )

There was no indication at that time what the options were that were being actively pursued but now we learn that the Office of the Assistant Secretary of Health (Dr. Koh's office) is going to have the Board on the Health of Select Populations at the Institute of Medicine (IOM) set up a committee “of thought leaders and stakeholders to comprehensively evaluate the current status of criteria for the diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).” (

The impact of the clinical diagnostic criteria they develop will be on the ME(cfs) community is a big question.

Earlier this year the IOM Board on the Health of Select Populations produced a report on Gulf War Illness (which they refer to as Chronic Multisymptom Illness or CMI – which is almost as board a categorization as the term chronic fatigue syndrome). (

That report seemed heavily focused on psychological concerns, and CBT and GET were included in their clinical practice guidelines for treatment of GWI.

This same report talks about chronic fatigue syndrome (that's how they refer to I) as being among co-morbid conditions with GWI, includes the 1994 Fukuda definition ( and the “2007 NICE Guidelines for CFS” ( and has the following pharmacologic and non-pharmacologic treatment recommendations for chronic fatigue syndrome:

Chronic fatigue syndrome


NSAIDs for pain symptoms

Melatonin for problems in sleeping

Antidepressants for depression and to improve sleep quality


CBT (cognitive behavioral therapy)

Graded exercise therapy

Lifestyle changes (for example, regular sleeping schedule; avoidance of caffeine, alcohol, and tobacco; and dietary changes)

Alternative therapies (for example, yoga, Tai Chi, acupuncture, and massage)

CPAP for problems in sleeping

This OccupyCFS post poses a few of the many questions that come to mind about the IOM initiative on ME(cfs) clinical diagnostic criteria.

Many view the GWI report as heavy on inadequate and inappropriate treatment approaches (for GWI and ME(cfs) among other things) with emphasis on psychological rather than biological processes.

The suggestion in the GWI report that CBT, GET, and a massage or two - or perhaps yoga, will treat our illness(es), and that in chronic fatigue syndrome (again, this is THEIR term, not ours), cognitive dysfunction tends to be mild, and that the report makes no mention of PEM/PENE, one wonders what sort of materials the IOM will be accessing to develop their clinical criteria.

Will the IOM produce clinical diagnostic criteria that accurately captures the complexity of ME(cfs)?

(By the way, it is estimated that an IOM initiative typically costs one million US dollars.)


Update 31 Aug 2013:

Thanks to those responsible for getting the response date extended to Sept. 11, 2013 (4pm Eastern time)


Hat Tip and MANY thanks to Leela Play for finding the notice.


Reposted from OccupyCFS

Thank you Ms. Spotila for drawing attention to this!

A Public Citizen

February 18th, 2013 Jennie Spotila Leave a comment Go to comments

When I wrote about the CFS Advisory Committee’s creation of a High Priority Recommendations document and how their process violated their own charter, many people asked me “What can we do about it?” Today, I can finally tell you what I did.

I contacted Public Citizen, a non-profit organization with the mission of serving “as the people’s voice in the nation’s capital.” Public Citizen has litigated cases under the Federal Advisory Committee Act, and has a Health Research Group that advocates for safer drugs and medical devices, equitable access to health care, and other issues.

On February 14th, Public Citizen sent a letter on my behalf to William B. Schulz, Acting General Counsel of the Department of Health and Human Services (you can read the full letter here). The letter details what I uncovered about the High Priority document, and asks the General Counsel to do two things:

We ask that you act to ensure that CFSAC complies with FACA and with its own charter going forward. We also ask that you return the January 2012 “High Priority Recommendations” document to the full committee for review, so that whatever action CFSAC chooses to take regarding those recommendations or any other transmission to HHS be debated and approved by the full committee, in public, as required by FACA.

It remains to be seen whether the General Counsel will act, and what he will do. There has been no official response as of today. However, upon checking the CFSAC website, I found that the High Priority document has been removed from the website. Perhaps this is a first step in correcting the Committee’s error.

I extend my sincere thanks to the people at Public Citizen who moved so quickly to assist me in this way. Sometimes, I feel like no one outside the CFS world cares about what we’re dealing with, and that requests for help will be met with disinterest or active disbelief. But Public Citizen did not dismiss my concerns or our disease. They recognized the public interest in the proper operation of advisory committees, and moved to help us. I am grateful for their assistance and support.

So what can you do? Help me boost the signal!!! Share my blog post, circulate it on Facebook and Twitter, and write about the Public Citizen letter on your own blogs. Tell your support groups and share it with all your contacts in the CFS world. Let’s ensure the community is informed about this action, and let’s monitor the progress together.

The full text of the letter from Public Citizen is pasted below:

Letter to Department of Health and Human Services Regarding the Chronic Fatigue Syndrome Advisory Committee

February 14, 2013

View as PDF.

By postal and electronic mail

William B. Schultz
Acting General Counsel
Department of Health & Human Services
200 Independence Avenue SW
Room 713-F
Washington, DC 20201

Dear Mr. Schultz,

On behalf of Jennifer Spotila and Public Citizen’s Health Research Group, we are writing to call to your attention to and ask you to halt violations of the Federal Advisory Committee Act (FACA) by a Department of Health and Human Services (HHS) advisory committee, the Chronic Fatigue Syndrome Advisory Committee (CFSAC), which is housed within the Office on Women’s Health. Ms. Spotila is a chronic fatigue syndrome (CFS) patient and activist who has a keen and personal interest in federal policy regarding CFS. Public Citizen’s concern for the proper functioning of advisory committees stems from its long history of advocacy, in both legislative and judicial fora, for openness in government proceedings and the regular participation of Public Citizen’s Health Research Group in the meetings of HHS advisory committees.

We have become aware of the following problem: CFSAC subcommittees have been transmitting recommendations directly to HHS officials without public debate and approval of the full committee, as required by both CFSAC’s charter and FACA. Specifically, at its November 2011 public meeting, the CFSAC decided to create a distilled list of its most important recommendations for the Secretary. But the process of creating the list of key recommendations for the Secretary did not occur in the full committee or in public. Instead, various subcommittees met in private to identify the recommendations to prioritize, which Dr. Nancy Lee, the Designated Federal Officer for CFSAC, then compiled into a single list that was discussed with Assistant Secretary for Health Dr. Howard Koh. The final document, dated January 2012 and titled “High Priority Recommendations from CFSAC,” was never discussed or approved by the full committee or in a public session. Additionally, the document was not posted on the committee’s public website for an entire year (the document is dated January 2012, but it was posted just last month).

CFSAC’s statutorily-mandated charter provides the following regarding subcommittees: “The established subcommittees shall provide advice and/or make recommendations to the parent Committee. The subcommittees may not report its [sic] findings directly to any Federal official unless there is specific statutory authority for such reporting.” The transmission to Assistant Secretary Koh of recommendations developed by subcommittees and never approved by the full committee constitutes “subcommittees . . . report[ing] [their] findings directly to any Federal official” in violation of this provision. Additionally, FACA § 10(b) requires that the minutes of advisory committee meetings be made public. By acting through subcommittees closed to the public to develop the January 2012 “High Priority Recommendations from CFSAC,” CFSAC circumvented the public openness requirement of FACA.

The FACA violations deprived Ms. Spotila and the public generally of important rights to observe and participate in the advisory committee process, which can have significant influence over federal policy. Making advisory committee recommendations through a public process allows interested members of the public such as Ms. Spotila to comment, enables all members of the full committee to contribute to the decision, and allows the public at large to review the work of advisory committees. Public oversight of the work of advisory committees is one of the central goals of FACA. See Cummock v. Gore, 180 F.3d 282, 285 (D.C. Cir. 1999).

We ask that you act to ensure that CFSAC complies with FACA and with its own charter going forward. We also ask that you return the January 2012 “High Priority Recommendations” document to the full committee for review, so that whatever action CFSAC chooses to take regarding those recommendations or any other transmission to HHS be debated and approved by the full committee, in public, as required by FACA.

Thank you for your attention to this matter.


Michael A. Carome, M.D.
Public Citizen’s Health Research Group

Howard K. Koh, Assistant Secretary for Health
Nancy C. Lee, Director, Office on Women’s Health