Thursday, February 24, 2011
Dog day afternoon at the NIH as Dr. Fred Gill, who hails from the psychoneurotic school of CFS, questions whether CFS is even a disease. He’s pitted against Dr. Harvey Alter and Dr. Shyh-Ching Lo, who believe in science.
By Charlotte von Salis
Curious to find out the National Institute of Health’s take on CFS these days, I attended the agency’s in-house lecture "Chronic Fatigue Syndrome: Is there a virus?" on February 22. One in a series in the NIH’s Demystifying Medicine presentations, the lecturers were the NIH’s Harvey Alter and the FDA’s Dr. Shyh-Ching Lo, co-authors of the 2010 paper "Detection of MLV-related virus gene sequences in blood of patients with Chronic Fatigue Syndrome and healthy controls.”
The third speaker was Dr. Fred Gill, a medical doctor and chief of the Internal Medicine Consultation Service at the NIH. He’s the self-proclaimed protégé of NIH psychobabbler extraordinaire, the late Dr. Stephen Straus. In addition, Seabiscuit author Laura Hillenbrand is a former patient of Gill’s.
So there I was, the sole member of the public, along with about fifty other NIH attendees. The good news: Lo and Alter were terrific. Lo, in particular, went to great lengths to explain how they carefully ruled out contamination in their study.
Gill: worse than expected
The bad news: Gill was even worse than I expected, touting graded exercise therapy as the best treatment for CFS. That wasn’t terribly surprising, as Gill worked with Stephen Straus and treated Straus's patients. Gill remarked that when he was in private practice, he asked his patients to exercise, and they improved. He noted that many patient advocates feel that exercise exacerbates their symptoms, but he believes exercise is the right treatment for CFS.
Gill gave kudos to the just-released PACE study. "For those of us who've been preaching this [graded exercise therapy],” he said, “it's nice to show this study." Gill was particularly pleased that the same fatigue questionnaires used by the CDC were also used in the PACE study.
Gill’s a big fan of the Centers for Disease Control’s Empirical case definition, AKA the Reeves definition. He loves the—gasp—"excellent" questionnaires that the Reeves definition used, as well as the CDC's 2006 gene study.
The clinician's approach, he said, should mirror the CDC's toolkit recommendations. Gill’s big on reassuring the patient, avoiding unnecessary tests, avoiding debate over whether it’s psychological, and above all, getting patients to remain active and exercise no matter what.
And the topper? Gill’s condescending presentation of a CFS patient whom he called Velma (a pseudonym). A middle-aged former pharmacist, Velma had a sudden CFS onset in 2006. She reported the classic CFS symptom of suddenly needing to sit down and then lie down. The next day Velma said she could barely get out of bed to go to the bathroom. Like many patients, she saw several doctors before getting a diagnosis, including physicians at the Mayo Clinic. (Given the center’s piss-poor track record with CFS, it’s not surprising that they couldn’t find anything wrong.)
Velma admitted to secondary depression. “It’s depressing when you’re debilitated, but I’m not a depressed person,” she summed up to the audience. While she’s better than she was five years ago, she still has crashes. She’s not concerned whether CFS is caused by a virus; she just wants to get well.
Velma explained that she takes fludrocortisone— a steroid that treats low blood pressure and neurally mediated hypotension, common autonomic nervous system problems in CFS. However, the patronizing Gill deemed this drug “useless” for CFS patients—despite that Velma said the drug helps her.
Velma reported feeling feverish and having swollen lymph glands, but Gill said he found no discernible fever or lymphadenopathy.
Pushing herself to exercise
Velma isn’t the typical CFS patient, as post-exertional crashing isn’t a big issue for her. She claimed, for instance, that she feels “much better” after she pushes herself to exercise on her “bad days.” That made Gill smile.
Gill, who looks to be well into his 60s, went through a series of ancient slides from the 1980s. Oh joy—he started by pointing out that CFS was first recognized as neurasthenia by Beard in 1869, and it went downhill from there. He went through the different names for CFS and selected case definitions (ignoring the Canadian).
Just in case anyone in the audience still thought there might be a real disease buried under the CFS construct, Gill ran through all the studies done by Straus that rebutted any positive treatment trials. Resurrecting his BFF Straus once again, he gave a big thumb’s up to studies done on stress and CFS. As to "pacing,” Gill oddly claimed that “he didn't fully understand pacing.”
Gill concluded his presentation by recommending the CDC's CFS website as well as that of the CFIDS Association of America (CAA). Gill said that he has a high regard for the CAA because he agrees with their views. So now it’s abundantly clear the kind of scientists whose thinking dovetails with the CAA’s.
I quickly and loudly called out that for real information, as opposed to misinformation, attendees should check out mcwpa.org and iacfsme.org. I actually got the attention of those present, many of whom copied down the URLs.
Alter explained that XMRV and related murine leukemia viruses (MLVs) aren’t yet accepted as human invaders or pathogens by most of the scientific community. (Sad, but true.) Alter also noted that scientists are still debating whether CFS is physiological or psychological. (Sad, but true.) He went through his slides, which unfortunately have been taken down from the course material website. My favorite was the last slide, which indicated that clinical trials with antiretroviral drugs could potentially prove whether XMRV causes CFS.
Alter said that XMRV is a simple retrovirus (compared to the more complex HIV) that could be passed on to progeny. He didn’t specify whether this infection occurred in utero, during breastfeeding or both.
Infection with XMRV, Alter said, can lead to viremia, which affects the immune and neurological systems. Alter explained that it made sense to look for XMRV in CFS because many patients have an acute onset that leads to a chronic illness, cluster outbreaks had been reported, concomitant herpes infections are common, and defects in the antiviral RNASE-L pathway have been found. He briefly addressed the XMRV and MLV studies to date, including the negative ones. To my relief, everything he said indicated that he continues to believe CFS is a serious, physiological disease.
Lo, too, followed his slide presentation. I'm kicking myself for not downloading the slides—I was surprised to find them gone from the course material website. Lo reviewed the methodology and findings in the joint FDA/NIH study in extreme detail (to this non-scientist).
His research team, Lo explained, developed a "highly sensitive assay targeting mitochondria DNA, mouse DNA, that are well-conserved in multiple copies" and used that assay to re-test the positive samples before publishing the study. Lo then brilliantly rebutted the contamination articles. As to the negative studies, he pointed out that differences in methodology, assays, and sample preparation were among the contributing factors that could explain the disparate results. He noted that two CDC samples tested positive for MLVs using the FDA assay.
Questions and answers
In the Q & A session that followed the talks, Gill was hopelessly out of touch, invoking the Simon Wessely school of misinformation about CFS, circa 1988, by insisting that the disease is "not common" in children.
During the Q & A, I said that the Canadian Consensus Criteria (CCC) should be used to select patient cohorts and that audience members should read it as well as Dr. Lenny Jason's "Development of a Revised Canadian Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Case Definition.”
I was cut off as I was making a statement rather than asking a question. So I don't know if what I said will make it to the edited videotape.
I did ask Gill a detailed question (mainly for the audience's benefit) about the Pacific Fatigue Lab's findings with repeat exercise testing, as well as the Lights’ exercise studies in CFS patients. Both groups of researchers found objective, measurable and significantly abnormal biomarkers that distinguished the sick from the healthy controls after exercise. Their findings allowed me to bring up post-exertional malaise as the hallmark of CCC-defined patients.
Gill replied that he disagreed with those studies but didn’t explain why.
In the Q & A, I told Gill that I was on the drug Midodrine for neurally mediated hypotension, and that was the only reason I was functional enough to attend the lecture.
Gill’s response was that studies have shown that there’s no orthostatic intolerance in CFS. Earth to Gill: Have you not read any of the formidable research by cardiologist Hugh Caulkins’ and pediatrician Peter Rowe’s group at Johns Hopkins?
Harvey Alter spoke again, pointing out that CFS has a viral-like “picture.”
Gill asked Alter, “Is CFS a real disease—and if so, what’s its etiology?”
Alter replied cryptically, as if he were the wisest of fortune cookies: “The answer depends on the effort to find the cause.”
Charlotte von Salis, an attorney, has lived with ME/CFS for 20 years.
Posted Thursday, February 24, 2011