The weekly research round-up includes recent publications about ME/CFS and Long Covid. We highlight the studies that have particularly caught our interest and follow these with the full list of publications together with their abstracts (summaries).
The ME Association maintains a comprehensive index of published research on ME/CFS and Long Covid that is free to use and updated weekly.
Audio Commentary by Dr Katrina Pears
ME/CFS Research Published 9 – 15 August 2022
There have been four new ME/CFS studies and thirteen studies on Long Covid.
We have highlighted two studies below:
Paper two (2) is a very small pilot study looking at immune cells under a transmission electron microscope (TEM), which are able to magnify objects up to two million times. This study only looked at the cells of four participants: a pair of identical twins (monozygotic) one with moderate ME and one without, as well as two unrelated participants (age and gender matched) one with very severe ME and a healthy control, i.e. this study had two people with ME and two healthy controls.
This study found some significant morphological differences in blood cells and mitochondria; compared to healthy controls ME/CFS participants were found to have:
- increased apoptotic (involved in removal of damaged cells) and necrotic cell (cell injury) death,
- swollen mitochondria,
- increase in platelet aggregation (process by which platelets adhere to each other at sites of vascular injury) suggesting a role of platelet activity in disease, and
- within the severe ME cells an increase in lipid droplet organelles, suggesting a lipid storage disorder.
- These findings were all in line with previous studies and showed some important correlations with disease severity.
Some important points to note from this study:
- Few other studies have looked at the ME/CFS cells in such detail under the microscope.
- When looking at healthy control cells under the microscope they do also have disordered mitochondria but it is the ratio of healthy to unhealthy mitochondria which matters.
- All participants were male, which is fine but studies have shown that males and female participants differ, so we don’t learn anything about this difference from this study as well as the fact that ME affects more women.
- There is a lack of detail about the participants, such as illness onset which could in term effect the immune cells.
- A strength of this study is the inclusion of identical twins which removes a lot of other variation which could be due to genetics.
- The findings from the in this study suggest new avenues for the pathophysiological nature of the disease and could be combined into diagnostic genetic tests (as shown in the severely ill participant).
This study although very small, provides some initial interesting findings, small studies like this help to build hypotheses (theories) which allows a new direction in research to be established and bigger studies to be funded, which I do hope happens. However, studies using transmission electron microscope are labour intensive so may never be high output studies.
Paper four (4) is a review article on already published studies on repeated maximal exercise testing over a 24-hour period, particularly focusing on VO2 max (measure of maximum oxygen consumption when exercising). The aim of this review was to report the main difference in the change between these two exercise events.
In reviewing the evidence, the main findings from this review show that, when completing a second exercise test (24 hours apart) that work rate (WR) at anaerobic threshold (AT) (and not a change in VO2 max) is reduced and is very different for people with ME/CFS compared to healthy controls. These findings are shown to be clinically relevant and useful for differentiating between people with ME/CFS and healthy controls.
This study was limited by the number of studies that could be included, with only four studies supporting the finding related to work rate (WR) at anaerobic threshold (AT). Despite this, the authors also predicted the proportion of future studies that if conducted in a similar setting would report similar findings, specifically where an exceeded clinically relevant threshold would be reached, this was predicted to be 78%.
There are a lot of interesting findings in this paper, showing reduced aerobic capacity in people with ME/CFS. However, I personally found this paper very hard to read and digest, with lots of acronyms throughout the paper. If you are interested in reading the full study, there is a read aloud function online.
In our weekly roundup on the 8th July 2022, we reviewed the recently published paper looking at treatment with oxaloacetate, here we addressed some of our concerns about this piece of research. We have been contacted by Alan Cash, the CEO of Terra Biological LLC who has provided us a response to our review, which we have provided below:
- One criticism of the theoretical basis of the work suggests that oxaloacetate cannot penetrate the cell and can thus not make a difference in metabolism. Our own work, in collaboration with Houston Methodist Hospital, using GC-MS based 13C isotopomer analysis (an analytical technique which can identify substances in a sample) indicates that oxaloacetate has absolutely no problem penetrating the cell. In addition, this argument that low doses of oxaloacetate cannot modify cell metabolism has been proven untrue by many peer-reviewed scientific journal articles, such as these already published studies by Wilkins et al., 2014; Conway and Cash, 2017; Augur et al., 2018; Kuang et al., 2018a; Kuang et al., 2018b; Ijare et al., 2019; Tungtur et al., 2021.
The US FDA has reviewed our detailed cellular work and has granted us “Orphan Drug Designations” for glioblastoma multiforme (brain cancer), hepatocellular carcinoma (liver cancer) and for Amyotrophic Lateral Sclerosis (ALS). In addition, the US FDA has granted us a “Fast Track” designation for the development of oxaloacetate in the treatment of glioblastoma. We have been working with a variety of groups including the National Cancer Institute, UCLA, the Mayo Clinic, Houston Methodist Hospital, the University of Kansas, and others to move forward clinical trials in Alzheimer’s Disease, ALS, GBM, ME/CFS, Long COVID and Cancer Fatigue/Brain Fog. These trials depend on oxaloacetate’s ability to modify metabolism at the doses given.
- Some of the participants dropped out of the trial– This happens in nearly every trial. Reviews of Randomized Clinical Trials published in the journals BMJ, JAMA, Lancet and the New England Journal Medicine indicated that 95% reported some missing outcome data (Bell et al., 2014).
In the ME/CFS trial, participants dropped out, for example, when they contracted COVID. No one dropped out of the trial due to the cost of the medical food, as it was supplied for free. A larger amount of people dropped out of the Long-COVID fatigue trial as recruiting was done via Facebook, and there was no economic incentive in the trial, whereas the ME/CFS patients were the personal patients of the co-author, Dr. David Kaufman. Surprisingly, even with dropouts, the data in this small pilot project was statistically significant in each dosage group, and overall.
- The study was done by Terra Biological LLC, which markets Oxaloacetate- This is true, but again this is true of nearly every drug developed in the United States, the pharmaceutical companies develop the drugs (Jaroslawski and Toumi, 2018).
It is surprising that this was considered a “negative”, as this is the standard practice, and it means that the company is investing heavily in potentially finding a treatment for the disease. To date, Terra Biological LLC has invested millions in research and development. Substantial additional funds for research in oxaloacetate have been invested by the National Cancer Institute, the Alzheimer’s Association, The ALS Society, and the American Breast Cancer Society and private funds. We note that the co-author, Dr. Kaufman, is highly respected in the ME/CFS community, and has no financial association with Terra Biological LLC.
- The control group used was historical- This is often the case in pilot studies, when it is important to control costs, and see if there is a result that bears additional investigation (Hall et al., 2020). In addition to the historical control, which used an oral medication and the Chalder Fatigue Score for analysis, a Meta study has shown that the placebo effect in ME/CFS patients is very small (Cho et al., 2005). Furthermore, the follow-on Clinical trial being conducted now at the Bateman Horne Center is a randomized placebo-controlled trial.
- The Chalder Fatigue Score was used in this trial because it could give a rapid picture of both physical and mental fatigue improvements. In addition to the Chalder Fatigue score, fatigue was measured with the PROMIS 7a Fatigue short form, and the Fatigue Severity Score. The results from these other fatigue tests were statistically significant. In the expanded RCT trial at the Bateman Horne Center, the following tests are being assessed: Chalder Fatigue Scale, Orthostatic Intolerance Symptom Assessment, Orthostatic Intolerance Daily Activity Scale, Rand36, Hours of Upright Activity, Fatigue NRS, Patients’ Global Impression of Change Scale, Dana Brain Vital, and blood samples are taken throughout the trial for metabolomic profiling.
In the USA, previous clinical studies established that there is a shortage of oxaloacetate in the blood plasma of ME/CFS patients as compared to normal controls (Germain et al., 2017). Because of this, and because oxaloacetate is a food, we were able to put oxaloacetate onto the market as a “medical food” to help ME/CFS patients—Now—instead of 5 years from now. We shall continue to keep the ME Association updated on our progress and thank you for providing a forum where we can respond to concerns.
ME/CFS Research References and Abstracts
Sandler CX, Cvejic E, Valencia BM, Li H, Hickie IB, Lloyd AR.
Front Neurol. 2022 Jul 25;13:935442.
Prospective cohort studies following individuals from acute infections have documented a prevalent post-infective fatigue state meeting diagnostic criteria for chronic fatigue syndrome (CFS) – that is, a post-infective fatigue syndrome (PIFS).
The Dubbo Infection Outcomes Study (DIOS) was a prospective cohort following individuals from acute infection with Epstein-Barr virus (EBV), Ross River virus (RRV), or Q fever through to assessment of caseness for CFS designated by physician and psychiatrist assessments at 6 months.
Previous studies in DIOS have revealed that functional genetic polymorphisms in both immunological (pro- and anti-inflammatory cytokines) and neurological (the purinergic receptor, P2X7) genes are associated with both the severity of the acute infection and subsequent prolonged illness.
Principal components analysis was applied to self-report data from DIOS to describe the severity and course of both the overall illness and concurrent mood disturbance.
Associations between demographics and acute infection characteristics, with prolonged illness course as well as the PIFS outcome were examined using multivariable statistics.
Genetic haplotype-driven functional variations in the neuropeptide Y (NPY) gene previously shown to be associated with brain responses to stress, and to trait anxiety were also examined as predictors.
The sample included 484 subjects (51% female, median age 32, IQR 19-44), of whom 90 (19%) met diagnostic criteria for CFS at 6 months.
Participants with greater overall illness severity and concurrent mood disturbance in the acute illness had a more prolonged illness severity (HR = 0.39, 95% CI: 0.34-0.46, p < 0.001) and mood disturbance (HR = 0.36, 95% CI: 0.30-0.42, p < 0.001), respectively. Baseline illness severity and RRV infection were associated with delayed recovery.
Female gender and mood disturbance in the acute illness were associated with prolonged mood disturbance.
Logistic regression showed that the odds of an individual being diagnosed with PIFS increased with greater baseline illness severity (OR = 2.24, 95% CI: 1.71-2.94, p < 0.001).
There was no association between the NPY haplotypes with overall illness severity or mood disturbance either during the acute illness phase or with prolonged illness (p > 0.05).
Severe acute infective illnesses predicted prolonged illness, prolonged mood disturbance and PIFS. These factors may facilitate early intervention to manage both PIFS and mood disturbances.
Jahanbani F, Maynard RD, Sing JC, Jahanbani S, Perrino JJ, Spacek DV, et al.
PLoS ONE 17(8): e0272703.
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex chronic multi-systemic disease characterized by extreme fatigue that is not improved by rest, and worsens after exertion, whether physical or mental. Previous studies have shown ME/CFS-associated alterations in the immune system and mitochondria.
We used transmission electron microscopy (TEM) to investigate the morphology and ultrastructure of unstimulated and stimulated ME/CFS immune cells and their intracellular organelles, including mitochondria.
PBMCs from four participants were studied: a pair of identical twins discordant for moderate ME/CFS, as well as two age- and gender- matched unrelated subjects—one with an extremely severe form of ME/CFS and the other healthy.
TEM analysis of CD3/CD28-stimulated T cells suggested a significant increase in the levels of apoptotic and necrotic cell death in T cells from ME/CFS patients (over 2-fold).
Stimulated Tcells of ME/CFS patients also had higher numbers of swollen mitochondria.
We also found a large increase in intracellular giant lipid droplet-like organelles in the stimulated PBMCs from the extremely severe ME/CFS patient potentially indicative of a lipid storage disorder.
Lastly, we observed a slight increase in platelet aggregation in stimulated cells, suggestive of a possible role of platelet activity in ME/CFS pathophysiology and disease severity.
These results indicate extensive morphological alterations in the cellular and mitochondrial phenotypes of ME/CFS patients’ immune cells and suggest new insights into ME/CFS biology.
Orji, N., Campbell, J.A., Wills, K. et al.
BMC Public Health 22, 1516 (2022).
Background: ME/CFS is a disorder characterized by recurrent fatigue and intolerance to exertion which manifests as profound post-exertional malaise. Prevalence studies internationally have reported highly variable results due to the 20 + diagnostic criteria. For Australia, the prevalence of ME/CFS based on current case definitions is unknown.
Objectives: To report prevalence of ME/CFS in patients aged ≥ 13 years attending Australian primary care settings for years 2015–2019, and provide context for patterns of primary care attendance by people living with ME/CFS.
Methodology: Conducted in partnership with the Patient Advisory Group, this study adopted a mixed methods approach. De-identified primary care data from the national MedicineInsight program were analyzed. The cohort were regularly attending patients, i.e. 3 visits in the preceding 2 years. Crude prevalence rates were calculated for years 2015–2019, by sex, 10-year age groups, remoteness and socioeconomic status. Rates are presented per 100,000population (95% confidence intervals (CI)). Qualitative data was collected through focus groups and in-depth 1:1 interview.
Results: Qualitative evidence identified barriers to reaching diagnosis, and limited interactions with primary care due to a lack of available treatments/interventions, stigma and disbelief in ME/CFS as a condition.
In each year of interest, crude prevalence in the primary care setting ranged between 94.9/100,000 (95% CI: 91.5–98.5) and 103.9/100,000 population (95%CI: 100.3–107.7), equating to between 20,140 and 22,050 people living with ME/CFS in Australia in 2020. Higher rates were observed for age groups 50-59 years and 40-49 years. Rates were substantially higher in females (130.0–141.4/100,000) compared to males (50.9–57.5/100,000). In the context of the qualitative evidence, our prevalence rates likely represent an underestimate of the true prevalence of ME/CFS in the Australian primary care setting.
Conclusion: ME/CFS affects a substantial number of Australians. Whilst this study provides prevalence estimates for the Australian primary care setting, the qualitative evidence highlights the limitations of these. Future research should focus on using robust case ascertainment criteria in a community setting. Quantification of the burden of disease can be used to inform health policy and planning, for this understudied condition.
John Derek Franklin & Michael Graham
Fatigue: Biomedicine, Health & Behavior
Background: Repeated maximal exercise separated by 24 hours may be useful in identifying possible objective markers in people with ME/CFS that are not present in healthy controls.
Aim: We aimed to synthesise studies in which the test-to-retest (24 hours) changes in VO2 and work rate have been compared between people with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and controls.
Methods: Seven databases (CINAHL, PubMed, PsycINFO, Web of Knowledge, Embase, Scopus and MEDLINE) were searched. Included studies were observational studies that assessed adults over the age of 18 years with a clinical diagnosis of ME/CFS compared to healthy controls. The methodological quality of included studies was assessed using the Systematic Appraisal of Quality for Observational Research critical appraisal framework. Data from included studies were synthesised using a random effects meta-analysis.
Results: The pooled mean decrease in peak work rate (five studies), measured at retest, was greater in ME/CFS by −8.55 (95% CI −15.38 to –1.72) W. The pooled mean decrease in work rate at anaerobic threshold (four studies) measured at retest was greater in ME/CFS by −21 (95%CI −38 to −4, tau = 9.8) W. The likelihood that a future study in a similar setting would report a difference in work rate at anaerobic threshold which would exceed a minimal clinically important difference (10 W) is 78% (95% CI 40%–91%).
Conclusion: Synthesised data indicate that people with ME/CFS demonstrate a clinically significant test–retest reduction in work rate at the anaerobic threshold when compared to apparently healthy controls.
Long-COVID Research References
- Post-COVID-19 neuropsychiatric manifestations among COVID-19 survivors suffering from migraine: a case-control study
- Symptom burden and immune dynamics 6 to 18 months following mild SARS-CoV-2 infection -a case-control study
- Comorbidity of long COVID and psychiatric disorders after a hospitalisation for COVID-19: a cross-sectional study
- Correlation of respiratory muscle function and cardiopulmonary exercise testing in post-acute COVID-19 syndrome
Dr Katrina Pears
The ME Association.