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Null Result

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“Appeal to ignorance – the claim that whatever has not been proved false must be true, and vice versa (e.g., there is no compelling evidence that UFOs are not visiting the Earth; therefore UFOs exist – and there is intelligent life elsewhere in the Universe. Or: there may be seventy kazillion other worlds, but not one is known to have the moral advancement of the Earth, so we’re still central to the Universe.) This impatience with ambiguity can be criticized in the phrase: absence of evidence is not evidence of absence.” ~ Carl Sagan. The Demon-Haunted World: Chapter 12 – The Fine Art of Baloney Detection.

I am feeling subdued. Jason contacted me back channel after our conversation in the comments of the last blog. We said what we each perceived to be a reach across the divide, but it quickly became clear that the distance was too great. I am deeply saddened by this state of affairs. ‘Scientific community’ is an oxymoron. Everybody in their own labs doing their little absence of evidence experiments, knowing nothing of the disease in question. Argumentum ad ignorantium. A false dichotomy. I own that I am one half of the dichotomy, though unlike the other side, I don’t fail to consider alternatives. The obvious third alternative here is there has been insufficient investigation to reach a conclusion. Unfortunately, it’s the folks with the above ‘vice versa’ view that we need to do the work in order to have enough information to know what is true and what is false. Deductive reasoning leads to blinders and inductive reasoning can go to religion; I acknowledge that. All valid alternatives must be considered. Hume’s Problem of Induction puts the current conundrum in a larger philosophical context.

Taking heart in the belief that regardless of the tone or outcome of our interchange, progress has been made with Jason. He will never, ever forget this and it will inform his life, even if it’s not conscious. Now he gets to decide if he is willing to see and be responsible for his assumptions and motivations. He’s just found out that there are consequences for those, even the ones you aren’t paying attention to. Especially the ones you aren’t paying attention to. It’s only a seed right now and who knows what fruit it may bear. Somewhere, somehow. Even if the only person he feels sorry for is himself, that’s a start. I articulated the ground he was standing on and he didn’t want to see it. And when it got handed to him plainly and clearly it hurt. Rightfully so, because I held up a mirror.

I didn’t even see a possibility for mediation. No common ground at all. It felt like a microcosm of the entire situation. The emperor has no clothes, but he is sighing with relief, because nobody is going to know. They aren’t going to have to deal with us. XMRV is going away. 

The divide that I was unable to bridge was our hope for reaching the promised land anytime soon. I don’t see it coming in the near future, unless it is from ‘left field’. Chronix? Andrew Mason’s lab? We can hope there are some others quietly going about their work, waiting for the dust to settle. I thought I detected real interest in Ian Lipkin when I met him. Here are Kent Heckenlively’s always incisive observations: The Wakefield Rehabilitation in Age of Autism.

I feel like a lightening rod, a lot of anger going to ground through me. Making people squirm isn’t my first choice, but I guess it’s better than being ignored. I’d rather be a lover than a fighter, but it seems it isn’t to be. I am propelled by the ‘atta girl’s I get from people who have had no voice for a very long time. It seems more important than who is pissed off or hurt.

More mail from Dr. Peterson’s patients. The jist is, he is really sad, but can’t say anything because of Annette Whittemore. And Annette Whittemore has never been willing to clear it up publicly either. These people are holding themselves out as our best hope. A little transparency is in order. I repeat. I have never met Dr. Peterson. Everything I know about him and what happened at the WPI came from the people there. Not one person, a bunch of people, but all hearsay and I plan never to repeat any of it. I believe patients first and foremost, so I apologize to Dr. Peterson. I don’t understand the apparent fixation with HHV-6 though. It seems so much less plausible than a retroviral etiology. I do admire his persistence above all else. Anyone dealing with CFS for 27 years without going insane deserves huge gratitude and congratulation for unusual survival skills and fortitude.

Like everybody, I hope the CFI gets somewhere. I’ve had a hard time getting past the name though. Seems kind of like the tee-shirt. I wish the ‘Initiative’ was not coming from the CAA, given their track record. I can’t find much in what’s been made public to suggest that resources will be spent looking for novel pathogens. We need more than a better definition of the problems, not that that isn’t important. Whether you like the CAA or not, it has managed to completely divide the patient community. Two different forums and never the twain shall meet! Very sad. Even we, the marginalized, can’t come together because so many see the powers that be at the CAA to be in bed with our captors. So ugly.
Transmission questions have been the hardest to answer, since I placed myself in the position of trying to answer questions. At this point, the scientific community has essentially alleviated you of any responsibility for transmitting a retrovirus. If my hypothesis is correct, pretty much everybody has something by now. It would appear, without the benefit of real epidemiological studies, that bad things went out horizontally at certain points, suggesting a few viruses with higher pathogenicity, or ones that combined in bad ways with what was already there; but by now, it’s pretty much of a mish mosh. What this means practically speaking for PWC’s is, sexual contact with healthy people may be more dangerous for you than them. I don’t hear that prior sexual partners of brief duration get sick, even many years later. I’ve heard occasional reports of spouses getting sick fairly quickly, but it seems to be rare. HIV precautions seem good enough for us too. 
From an internet friend who is helping me to stay positive:

Emotions run high because there is a huge reservoir of feelings and thoughts that has had no outlet for years and years. So many have suffered silently, trying to be good so they could be believed, much less helped. It’s one thing to ask for help and another to become a supplicant and plead and beg. Unfortunately pleading and begging is what we’ve been reduced to. Seems like birthing a new paradigm is just like any other birth, difficult and messy, but oh, the results matter so much. We have the old paradigm fighting tooth and nail to stop an unstoppable process. Progress will be made in strange, uncomfortable ways, but move forward we will.

Today’s song: World on Fire


Some answers…

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Although the personal questions in the comments of the last blog were asked very rudely, I will try to answer them anyway. I have represented myself as an open book, and I truly am, even though it gets me in trouble, as witnessed by the tone of the questions. Most of this has been said before, but things have changed, and perhaps it needs to be said again, from our current vantage point. So, I’ll give it a go.
I am not trying to persuade anyone to take anything. I share my reasoning, with references, within the limits of my writing ability. I intentionally report before I know the outcome so that it won’t be seen as my pushing a particular protocol. I am in the same boat as everyone else. I don’t know what to do to fix it. I don’t believe that anyone else does either. Arv’s are only one of the treatments I have written about here. I am sharing my thoughts and experiences in real time. 
This is a blog. Opinion. If you read it carefully, there are inconsistencies. I even reserve the right to change my opinion from time to time. I try to summarize occasionally, but yes, a “casual” reader might come away with something I didn’t intend. I am not sure what to do about that. I cannot recapitulate the entire blog each time I write. It is an ongoing discussion, not “the truth” at a moment in time. Almost everybody gets that, I think.
I am endlessly surprised that my opinions are so controversial and can evoke such ire. Most of it seems common sense to me. It is incredible, and very telling, that there are actually people that want to restrict my freedom of speech! Why does anyone care if others find my musings useful? I am not telling anyone else what to think. I have said repeatedly that I could be wrong about anything. If I were to say nothing until everything is scientifically validated and I was positive, I would never say anything at all. I am learning as I go, as is everyone. For some peculiar reason, I seem to need to write, and some people find it helpful. The blog is the best I can do, with the limited energy and time I have left, and I am grateful for it. When Ali suggested I write a blog, I didn’t know what a blog was:). The patients who comment and write are very sophisticated and opinionated all on their own, not needing me to tell them what to think. They ask for my thoughts so they can put the information into their own equations, not take it as some kind of truth written in stone. The reflex to restrict what I say so that the poor gullible patients won’t hear it is patronizing. And to the conventional physicians who might be reading, why the sudden concern for our well being? There are many useless things that you are willing to prescribe that are much more dangerous than arv’s.
I have never claimed to be anywhere near “well” and I have said all along that there were confounders with respect to our treatment with arv’s. As noted in the comments, gamma retroviruses replicate by clonal expansion, so we need specific drugs, but transcription of viral proteins and the assembly of new viral particles may be involved in pathogenesis, if the hypothesis is correct. I am endlessly reevaluating everything with new information as it becomes available. I am not in fact a “true believer”. I would love to hear any alternative hypothesis that fits close to as well. Anything at all that might suggest a direction to turn for efficacious treatment. I am dismayed that we are back to having an idiopathic immune disorder, albeit repackaged to sound like good news. Redefining it as a syndrome, yet again. 
There is no way to know if arv’s are helping us at this time, as I have said several times. I expected viral load measures and other ways to monitor that didn’t pan out. I did monitor several likely parameters which showed trends, but not convincingly enough to be useful. There are specimens sitting at the WPI that might contain valuable information. I certainly hoped it would be less ambiguous than it turned out to be. But there are others that experienced what we did, apparent cause and effect improvement from starting arv’s (often after an initial mild symptom flare). Some of them have written on this blog. I am NOT saying anyone should take arv’s, and never have, only that they shouldn’t be forbidden. The main problem I have recommending it as an option now, is that because it isn’t being studied, anyone starting will likely find themselves where we are, not knowing what to do for the long haul, and no help coming anytime soon. I actually think it is probably mostly a moot point now; the forces against have essentially won, shut it down for all practical purposes. The important thing isn’t really even arv’s, which at best only help incompletely, but our inability to get any help at all due to the attitude displayed in the reaction we have seen to the idea.
There are many drugs that are used because they work, even though the mechanism is unknown. One would think that for a debilitating disease which affects millions of people, for which there is no meaningful treatment, somebody would want to find out if that might be the case here. The usual way that happens is somebody has a good case, publishes it and then it gets studied. I have reported our experience. The burden of proof is not on me. What if it was a serendipitous discovery for the wrong reasons? The reaction of the medical community to trying arv’s is irrational, as the reactions of the medical community often are, especially when it comes to anything to do with this disease. The reaction of the scientific community is a joke, with no basis for an opinion at all; practicing medicine without a license, understanding nothing of the disease about which they are so opinionated.
Take a look at this paper: Zidovudine in primary Sjögren’s syndrome. Steinfeld. Rheumatology (Oxford). 1999 Sep;38(9):814-7. Did everyone get up in arms about this small clinical trial? Were the authors discredited for trying it? It doesn’t look like anyone followed up on it.
I have shared many personal details here, both physical and emotional. I have been very forthcoming, approaching undressing in public at times, so it is strange to be accused of “hiding”. The problem is that my sharing a list of symptoms that are “better” than before isn’t terribly illuminating, since some things are better or gone and some things aren’t. I even have a couple of new things. Like most ME/CFS patients, my condition changes from day to day and tweeting my moment to moment condition would benefit no one. However, I will try to define the big things. 
The most tangible thing that happened to me, seemingly from arv’s, was the near resolution of my chronic malaise. I had it much of the time for 15 years. It went away shortly after starting AZT/Isentress and I almost never have it now. So 90% of the time before, 10% or less now. That alone was life changing for me. 
My down periods used to last for 5 days to a week at a time, and now, rarely more than part of a day. The worst moments happen less often.
When I started arv’s, I never slept more than two hours without awakening, and I didn’t dream at all. I now often sleep all night with one or two awakenings and I dream normally. My day to day wellness is linked to the quality of my sleep in a chicken or egg fashion, so this improvement is key. 
Painless migraines (scintillating scotoma without headache) and hypertensive crises are much reduced in frequency.
Another “big thing” that happened: I experienced a definite decrease in my peripheral neuropathy pain at one point early into arv’s. However, trying to explain one’s pain to anyone else is an exercise in futility. The pain I have now is worse than pain that almost drove me insane at the beginning of my illness, but my coping skills are very different. Still when the reduction happened, it seemed definite. I am not pain free, but my pain is quite tolerable and does not require pain medicine. Others have also reported less pain on arv’s. Again, I am reporting, not selling. For everyone who thinks they were helped, somebody else thinks they weren’t, but the risks of trying it are pretty minimal with proper monitoring.
I acknowledge that it is possible that all these things happened in spite of, and not because of, arv’s. 

A big disappointment for me has been that the abnormal response to big time stressors remains, though it may be attenuated. Impossible to tell.

As for my daily functioning? I am able to work long days, most days, electronically (phone, Skype, email). I don’t have brain fog, but do sometimes have more symptoms after mental exertion. I am limited physically, more so in Santa Fe than Hawaii. I can climb a couple of flights of stairs with some dyspnea, more if needed, if I go slowly. I can usually walk several blocks, but might have some mild PEM if I overdo it, though my exercise tolerance is very variable. I don’t need handicap parking. I have no difficulty lifting groceries, etc. Resistance exercise is easier than anything aerobic. Swimming is easier than walking. Standing still is the hardest. The most physically challenging thing I have to do is negotiating airports and I use the airport wheelchair service for that. Gentle yoga is helpful. Pretty much all of the above is better than before I started arv’s, though as a commenter said, and, as I have said all along, other things happened too, before, during and after. Also my illness historically follows my state of mind (knowing full well how unPC it is to say that out loud). I am also much more tolerant of symptoms than I used to be, and not a very compliant patient, more confounders. 

I can only work part-time face to face, a couple of hours at a time, but I’m OK for many successive days. I could fake it for longer hours than that, but don’t want to do that. My patients travel a long way to see me, and I want it to be useful and special. I am seeing new patients for 4-5 hours on two different days, which is working out well for all concerned. It is a unique, collaborative endeavor. Sick doctor and sick patient. I am limited, but can function fairly reliably, though there are days when it’s tough; however, there are more days when it isn’t. 
When I started arv’s, I was unable to speak on the phone, because of auditory processing disturbance. I also had to lie down most of the day, only sitting or standing for a very short time, and I now sit up most of the day. Standing is more difficult some days than others, but there is never a time when I can’t if I need to; that was not always true. 
So huge functional change in the last 20 months on arv’s, but improvement started about 6 months before that, with cessation of Lyme and symptom-based treatment. From housebound to functional, but not at all “well”. I have written about the reasons why I abandoned the use of rating scales to evaluate our experiment and don’t want to rehash it again. It is sad that it’s all we have. I am collecting them on my patients, but don’t expect them to be as useful as patients’ subjective reports. Yes, I do believe what my patients tell me.
My illness certainly isn’t gone, though it has lifted, lessened, but it is a relapsing, remitting illness all on its own, making it extremely difficult to assess cause and effect. I have said this over and over again. I am fully aware that many ineffective or harmful treatments have been perpetuated because of this feature of the illness (see my prior blog entries about Lyme Disease treatment). Whenever anyone gets better, they think it’s because of whatever they were doing at the time. I received an email recently from a patient who was housebound for fourteen years and suddenly improved enough to get a life, having changed nothing. I was of course influenced by the fact that there were two of us sharing the same experience; Ali and I had similar experiences with respect to the timing of improvement, though she had no side effects and I did experience a flare of symptoms initially. And for the record, neither of us has a history of placebo responses. 
Ali went uphill during her first 6 months or so on arv’s, but had more therapeutic interventions concurrently than I did. The goal was always to get her better, not demonstrate something scientific to others. Her treatments did not prevent her crash when she tried to engage life again a year ago. She is doing well again now, but it is impossible to say if this level of wellness is the same, above or below her last remission. The “crash” didn’t become as serious as prior crashes have been for her. The important thing to her now, I think, is that she is better at this moment, and seems still to be slowly improving. Will it last? She is savoring it while it does.
My baseline was better prior to the events of early July than it is now, though I am not “crashed”. I have been under a great deal of stress, though I am hoping things will calm down a little now, so I can regain what I have lost. There is no way to know if I tolerated the crisis better than I would have without arv’s. I suffered the kinds of losses and persistent stress that have historically set me back in a major way. I stopped Isentress a while back, and am worse. Cause and effect? Who knows, but I don’t want to stay on monotherapy and am afraid to stop Viread, since a couple of patients who were forced to go off have lost gains. I may go back on Isentress. Also thinking about Lexiva (see Li on the sidebar).
I have received several demands for an apology from me to Dr. Peterson. As I said when I mentioned his name for the first time, I have never met him. Making enemies was never my intention, just the inevitable consequence of stating one’s opinions openly and publicly in such a contentious arena. My frustration feels overwhelming sometimes and it comes out in my writing. I hear from patients that love Dr. Peterson, and that does make a difference to me, but it still seems inconceivable that he abandoned the pursuit of a retroviral etiology when he jettisoned the WPI, knowing what he knows about the science and the disease. His teaming up with Konstance Knox to sink the WPI still seems really sleazy to me and his claim that it was to protect patients disingenuous. He could not have known there were problems with the VIP Dx test, or questions of contamination, at the time that he left, so how could he have been “right”. His agenda appears to go beyond figuring out how to treat the disease and help patients. I am not saying that I know precisely what that agenda is. It would seem that everyone who was involved with the WPI was hurt, likely including Dr. Peterson. I only wish that he hadn’t thrown the baby out with the bath water. 
I regret any pain that I have caused, but some truths are painful. For me, it is painful to acknowledge how few friends there are worth having in the medical or scientific communities. My referral list for mainland doctors is a very short list. When I think back over the people I have mentioned by name in an angry or personal way, it is a select few that had it coming. My lack of professional decorum, or whatever you want to call it, comes from outrage, and mostly justified. I challenge anyone who has been sick with this disease for any length of time to write their truth and not say some angry things. My writing is also full of hope for the future. It’s just that it is the hope of learning to live well with the disease, rather than to truly vanquish it any time soon.
I really think many have too much confidence in “science”, especially retrovirology, which seems to have an unusual number of landmines scattered across its landscape. Even if Dr. Lipkin were to say tomorrow that he agrees that there are gamma retroviruses infecting ME/CFS patients, it will be a long time before that translates into specific treatment. Compassionate use of existing drugs should be tried and available, especially for the sickest patients. There are possibilities besides arv’s. Lenolidamide? Pentoxyfyllin? Nexavir? Existing drugs. What others? I recently heard of a big time response to Copaxone. Is anyone looking in a systematic way? Really looking? Why does it feel almost subversive to talk about it? The idea that these patients should, or can, wait is indecent. Again, I am not trying to convince anyone to do anything other than consider my ideas. I continue to write because some find it helpful, and I have made many friends, but I have made enemies too, and that gives me pause. I do grow weary of the personal attacks, on top of everything else that has happened recently. I need to focus on my patients, but want to continue to reach out to readers; there is so little information with respect to how and what to consider for treatment in the here and now. Five or ten more years is too late for many of us. 
OK. Now I have some actual work to do:).
Aloha,
Jamie 
Today’s song: Can’t Find My Way Home 

When One Door Closes…

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I believe this demonstrates a social ‘immune system’ in science which is remarkable for its ability to distinguish ‘self’ from ‘other’.  ~ From my email 

I feel like we are post-op. The patient got opened, the problem identified and resected, but the smallest movement produces a wince of pain. Still, it is becoming clear, there will in fact be a future. The dilettantes, fair weather friends, have all gone home, closed the shutters, locked their doors, and minds. Nothing more to think about. We have been easy to ignore for a long time. Now, it’s even worse than that. The scientific community is actually making fun of us in their ignorance, as is the CAA, our supposed representatives, who in 20 years have never managed to sound the alarm. If XMRV wasted some money, what about the CAA? If these scientists were truly objective, they wouldn’t all be so happy about the outcome. Mikovits, Ruscetti and Hanson, a very few others, are the only scientists in the world who know anything at all about the disease. And the fact that they care about us, doesn’t make them wrong. The rest of the scientists in this story are completely ignorant of the pathophysiology. Clueless, and not interested. Racaniello, ERV, commenter Jason, et al have not an iota of understanding about why simple retroviral disease is such a good fit. To them, it’s all about a test, not a disease. Money, glory, fame. Most certainly not about patients. They seem shocked to find out there are real people impacted.

The idea that it is better for the patient community if research into gamma retroviruses stops now, so that all the money can be spent on investigating the same old downstream effects and known pathogens, is a cruel joke.

From the limited anecdotal evidence we have, I’m pretty sure the response to antiretrovirals, even without specific drugs and without a PI, is better than placebo. The AIDS community doesn’t want to share their drugs, even though they are available to healthy partners and prostitutes for prophylaxis. Doctors who have already prescribed antiretrovirals are now, on the heels of the BWG results, refusing to refill prescriptions for their own patients who have improved on them! What could this be but politics and money? Why is the scientific community invested in creating a prohibition against these particular, not very dangerous, drugs? Why so much resistance to the idea of a retroviral etiology that they are gloating as the hypothesis takes a hit. Let’s have a party and burn Judy Mikovits at the stake. Glee. At our expense. Like psychopathic children who enjoy pulling the wings off insects. This, while babies are born with it, new cases are occurring every day and huge numbers of patients, already sick for decades, circle the drain.

The question of whether antiretrovirals are helpful or not and for whom, is a question that hasn’t even been asked, let alone answered. It is politics, not medicine, that prevents it from even being considered. The clinical piece still strongly suggests a retrovirus, or retroviruses. It is possible that it isn’t only gamma retroviruses. ALV’s, alpha retroviruses, do pretty much the same things as MLV’s. Although it is likely that ALV’s would be less infectious to human cells than MLV’s, because of phylogenetic distance from mammals, there is evidence in the literature, by none other than John Coffin, that suggests, under some circumstances, it is possible for ALV’s to infect human cells. But he didn’t think we should worry about it: Science Fiction? and Pure Speculation (I can see and hear the virologists, rolling their eyes and snorting, all the way from here). So what’s the motivation for making sure this hypothesis is found wrong? If it is right, it’s responsible for bringing down the health of the species, so some might be a little invested. But it’s so big, that saying it out loud makes you sound crazy. We have a possible source of infection: parenterally administered simple endogenous animal retroviruses. What else causes both neurological disease and cancer? Methylation issues, multiple gene activation in the same patient, persistent immune activation, multi-generational neuro endocrine immune disease. Think top down. What else does that? The fact that not everybody gets sick, that there are various opportunistic infections, that it goes in different directions in different people, that it is of variable onset shouldn’t be so bewildering. There is obviously a greatly increased risk of ME/CFS in the partners, children and parents of patients. Too much autism found in the same families. IT IS AN INFECTIOUS DISEASE. Where are the epidemiologists? 
There have been lots of questions, people asking for clarification of the last two blogs I wrote. For the most part, if it was ambiguous, it is ambiguous to me, at least I wouldn’t personally testify to it, especially anything about who did what for the BWG. I don’t think there are any villains in this story. Only people who lost their way, sailing into open ocean in a dense fog without a navigator. People are fallible, and we are where we are because they never had a chance. Much of what ensued was like middle school more than anything else. Nothing sinister. No malice and absolutely no aforethought. It still has a middle school flavor to it, all the way to bullying in order to cover-up.
What I meant by saying that the XMRV testing that was done at VIP Dx is now null and void is that there were likely many false negatives and false positives; therefore it had no clinical utility. It cannot be interpreted. However, everyone knew that it was experimental. At the time, we were grateful to have it. Dr. Mikovits stands by the testing done at the WPI research lab. My understanding of her position is that she was not responsible for quality control or precisely which assays were used at VIP Dx, after the initial release of the test, when Cooperative Diagnostics made their bid for the market. If contamination occurred, it sounds like it wasn’t necessarily with VP62, but with the cultures from hot patients (like us). Apparently, what has been learned through all this is that the labs need to be using precautions required for Mycoplasma. Retroviruses have not been thought to be aerosolized previously, but now it seems, some probably are. There are two papers that show rapid spread through a clean lab in a couple of days, Zhang and Sfanos, linked on the sidebar. The serology is picking up proteins that are, if not actually to HGRV’s, at least very similar to MLV proteins. It has nothing to do with XMRV per se, and cross reactivity has not been ruled out. At least this is how it’s been explained to me, though I know very little about the technicalities of lab testing; more than I used to, but still not much. Therein lies a key problem, little sharing between doctors and scientists.
The slide issue seems like a tempest in a teapot to me, part of the same insanity that requires Judy Mikovits to be a perfect human being or all is lost. There is now an investigation, so in the end, we will find out what the designated judge says. What I would like to know is, how did Dr. Mikovits’s firing go from ‘insolence’ to ‘fraud’ from Thursday to Monday? Dr. Mikovits was fired on September 29 and ERV blogged her over the top accusations on September 30, I’ve been told, though I still have not been to her blog (thousands have visited mine from her site). Who fed it to her? The editors at the Chicago Tribune should be ashamed that Tsouderos was taken in. Nothing more than tabloid journalism. For the record, I waited three days after Dr. Mikovits was fired, before I wrote anything. By then, it was clear to me that it had been decided that Dr. Mikovits’ reputation was the price of the WPI’s survival and my inbox was full of unanswerable letters. I said nothing for a very long time, hoping for a different outcome. Also for the record, I did not send any letters to the press. Trine Tsouderos wrote to me and asked me what I meant by lock-down. I told her “The personnel was locked out of the lab.” (proof of which is on my computer). Nothing else came from me. 
Obviously, something went very wrong. Most likely lots of things did. I know Dr. Mikovits would like to have the chance to figure out what. I think the probability that what went wrong was a ‘fraud’ committed by Judy Mikovits is at the very bottom of my list of possibilities. I know her personally and it seems beyond improbable. Inevitably mistakes were made and everyone on the planet has something to hide, so, poor Judy, and poor everyone else involved.
I hope to never be an insider again. Two people have asked me how I could have forgotten what the Whittemore’s did for me. I have not forgotten, but they seem to have forgotten what Dr. Mikovits did for them. I was videotaped for the WPI saying they had saved my life, and it was true. I said nothing, except that I had been fired; I said that because I wanted to distance myself from the decisions being made there. But then Dr. Mikovits was fired. If I hadn’t written anything, Trine and ERV would have had the only say. But I am not going to engage in any further mudslinging going forward. I am now supposed to apologize to this one and that one, who was right because the interloper has fallen; the WPI was wrong and I stood behind them. I was a starry eyed kid then, believing that the cavalry was actually coming over the hill. I am a battle weary soldier now, having taken a few arrows in the heart. I no longer think the cavalry is coming at all, any time soon. Also, I still think that all the people I mentioned at one time or another on this blog in a negative context have behaved very badly, even if everything the WPI ever did is wrong. It’s not black or white. It never was and it never will be. The patients are the ones that get screwed, over and over again. CAA, the most divisive force in our community, HHV-6 Foundation, WPI, it doesn’t matter. Loss and more loss.

So, “Cheshire Puss… Would you tell me, please, which way I ought to go from here?”, said Alice to the Cheshire Cat.

Since I am feeling like my change the world phase is over, as Kita said, what next? My job now is to interpret the events in terms of their clinical significance, one on one. Primum non nocere is my guiding principle, as it was for my first 25 years of practice. When possible, I include the pocket book in that. It is curious what insurance will and won’t pay for, having very little to do with what might produce results with the least risk of harm. In my practice, I am using only LabCorp and Quest for labs. I am no longer interested in results from labs that have a stake in the results.

My attention is on my daughter, as it has been all along. She was “Harvard material”, as my step-father, a Yale/Harvard educated surgeon, said before he died of the late effects of treatment of his Gleason 9 prostate cancer. Ali still might succeed at having a life with the right physical and social support. For a long time I have envisioned a collective with the goal of creating a supportive, assisted living environment for young people with CFS. It is clear to me that I will be dead before there is treatment that approaches a functional cure. Whether you think arv’s are a good or bad idea, we are both doing well on them. Ali is engaging her life again, dating, going out, shmoozing with her illness. Not suffering much at all. Last time she was at this point, she did too much too soon. She is wiser now.
She is very responsive to the right treatments, now that we know what we are treating (not a specific pathogen, but still a context and approach to the illness). Folinic acid is hot stuff for her, Leucovorin 10mg IV weekly for a while, and now she is playing with the oral form, finding some of the same side effects as with Deplin. It appears to build up over a period of time, days to weeks, and cause dose dependent sleep disruption. But some amount helps the overall picture. I am hearing similar things about Deplin from patients. Important initial response, then dose related insomnia, sometimes still with improvement in other things. For Ali, the amount of folic acid derivatives required for positive effect without sleep disruption seems to be decreasing with improved wellness. So she’s tinkering. Next stop, 5-MTHF. I’m starting to order MTHFR mutation testing on my patients (MTHFR Thermolabile Variant DNA Analysis at LapCorp and MTHFR DNA Mutation Analysis at Quest). 

She continues to use oxygen with great regularity. We both find it useful for rescue, as well as believing that it supports our recovery, which seems steady and real, but slow. There was a single comment a while back that oxygen had been bad for someone, but without specifics. I want to hear about any problems, since I’ve been advocating its use. I have a lot of experience prescribing oxygen as a hyperbaricist and the risks, without adding pressure, are so minimal as to be almost non-existant. You can always turn it off, after all. Long term, there may be a risk of accelerating aging. That’s all I can think of. I can’t really come up with another reason not to try it, but I certainly want to hear it, if someone has something to add to the discussion. So far, practically speaking, my patients are liking oxygen. It is representative of the insanity in all this that patients can have Fentanyl patches for years and years, but can’t try an oxygen concentrator.
My illness is pretty much refractory to everything, except being positively engaged. For me, helping helps the most. I do best when I don’t mess with it much. I was the sickest when I was taking the most drugs. Antiretrovirals are one of the few things that actually seemed to move me. I sent specimens to the WPI regularly during first year of our experiment. Dr. Mikovits had evidence of our positive response to antiretrovirals, at least initially. I wonder where those specimens are now? I’ve tolerated 5 trips to Reno and 3 to Hawaii in the last 13 months. Pretty good for an ME/CFS patient who had been desperately ill twice in the previous few years. It is becoming clearer and clearer that I do feel better in Hawaii than Santa Fe. I think for me it is the elevation, because Santa Fe is one of the cleanest cities in the country, Los Alamos aside. However I’m hearing from lots of people that say they felt better in Hawaii but who live at sea level (and others who didn’t get better there of course). Some of those people live in really polluted places, like LA and NYC, so that may be the greater factor for them.
I am in complete and total agreement with the mold warriors that environment is critical to success, defining success as the patient’s maximum possible wellness within the context of an incurable, but remittable disease, though my idea of environment is much broader, not just avoidance, but feeding the positive, including strengthening the spirit. Stress makes us sick. My fantasy kibbutz would be organic, as chemical free as possible, MCS friendly, and of course as mold free as achievable. But as important, would be an opportunity to be alone, with necessary help, or to be able to with others who understand and support. To be able to go out, but not fear ruining it for everyone else, if assistance is needed. To not have to apologize for existing. I see the mold warriors insistence that I am the enemy as a microcosm of what anybody with this disease who finds a way out feels. Huge frustration that they aren’t being heard in the face of immense unnecessary suffering. It’s just that from my perspective, hearing from people from the full spectrum of the ME/CFS community, it’s one of many factors, most important for some, but not so much for others. 
Almost the most important thing that didn’t happen at the WPI clinic was the use of an electronic EMR by multiple clinicians, so that a large database would be created, which would ultimately be searchable by any parameter chosen. I am using Practice Fusion, free cloud based EMR. It is brilliant. It can only improve patient care for doctors using it. Converting from another method of documentation is difficult, but it’s not insurmountable. It’s possible that physicians might be able to contribute to the creation of a large patient database anyway, even though they are not physically in the same place. I mentioned a particular test above; it is beyond time that clinical research (pardon the oxymoron) was happening in a broader context than one physician’s practice. Thinking about this, and what might be still be possible…
Tonight’s song: Closer To Fine

What Next? by Kita Rael

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Time to stop feeding the beast that is intent on eating us. I believe that until some sort of money making model is invented to reap CFS/ME, our community will be the target of and subject to parties and people whose job it is to keep us divided, traumatized and so focused on that trauma that we are rendered as politically disabled as many of us are physically disabled.
Can you see how this takes us off the playing field? The one we just really stepped on with so much hope not too long ago? We finally found our voices. The thing to remember is that these are OUR voices and they weren’t given to us by research, they were inspired by research. And research/government/science/(whatever) cannot take them away unless we give them away.
Yes, there is howling pain when there is a setback. What looks like a huge crash right now may well prove to be a really big speed bump, on the order of what I once encountered while driving around in Mexico. The dreaded “tope” (pronounced toe-pay). It’s about three times the size of our American speed bumps with sharp corners. If you’re not paying attention they can be lethal to your tires. So one person was appointed to watch and would sing out “TOPE!” in order to avoid more problems than were required on this particular trip.
I vote to call these latest events a pretty big tope. Everyone had their eyes on the horizon and were speeding up. Then bang. Now we are on the other side of it, maybe sitting on the side of the road. Damage is being assessed. There are some of us in fistfights in the back seat and it’s taking all of the attention off of the road. Yes, we’re still on the road, it was just a tope.
Pay no attention to the onlookers who are trying to tell you that the damage is so terrible that they will have to help tow your car off to the repair shop, (there to “try” to repair it and possibly even causing more problems than you arrived with in order to make that tope into such a disaster that you can’t continue on your way) even though, with careful inspection, you can see that you’ll probably be okay. It’s worth getting back in the car, quelling the uproar in the back seat, turning the key and easing back onto the road and heading further towards your destination.
We still have our voices. We’re still moving forward, even if we took a bigger hit than we thought possible to sustain. There will always be outbreaks of fighting in the back seat even after periods of relative quiet and harmony. An elbow will be thrown, someone will feel crowded, someone else really enjoys a tussle. The car keeps moving. Now and then it’s time to switch drivers. Either a driver got tired or their stop came along, a different destination than the majority in the car. We just saw a designated driver pitched out, but who says there can’t be a way to circle around and pick her back up, dust her off and cheer her amazing driving skills once again?
But guess what? We patients OWN the car and we actually do have a say in where it goes and how it gets there. Every time research/government/science/(whatever) throws a wall in front of us we can go around! What will we do when it’s actually a wall and not a tope? I say this was a terrific exercise in preparedness and courage and fortitude. Our community is diverse and filled with inventive and capable people, sick or not. A great example of that was the write-in campaign that morphed into such creative forms that it was stunning. Who knew? Who knew what we could be and do until it got started? We have deep resources in the people around us who DO care. That’s a proven thing.
I don’t know about you, but I still feel excitement in the air and movement with our community and also with investigations on the part of researchers. This is so different from the 25 years of stagnation that preceded the Science paper. Like it or not, the dam was breached and here comes a flood. I do not believe it can be stopped because there is the weight of aware and passionate people pushing ahead.
Again I say that I hold with this: he of the highest light wins.

No Good Deed Goes Unpunished

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Yesterday made clear that it is going to be a circus. All that’s needed is cotton candy and clowns. Annette Whittemore is still selling fairy dust and the fate of humanity depends on whether Judy Mikovits was perfect or not. It’s more exciting than a high wire act. The CAA, the folks at the CDC, most of the scientific community are all gleeful. They wanted to turn the iconoclast into Joan of Arc. Since she isn’t a saint, the Salem Witch Trials is a better metaphor. If the scientific community had actually been impartial, they wouldn’t be so happy. They say it needs to be about the science, not the scientist, but in fact, it was, and is, very personal, not about the science at all.

I am not a lab scientist and cannot evaluate the slides written about in yesterday’s Chicago Tribune. I refuse to read ERV’s blog on general principles. Trine Tsouderos seems to be slumming for sources. And Annette Whittemore, who has no viable option but to blame Dr. Mikovits for everything that ever happened at the WPI, has turned to the journalist with an agenda. The debunker. Necessity makes strange bedfellows. Even discounting my own experience of Dr. Mikovits, which makes fraud as an explanation for an error extremely unlikely, it makes no sense that she would intentionally subject herself to the possibility of that fraud being detected by using the same slide again on purpose. The only person who has a reason right now to characterize a mistake, if one was made, as fraud, is the person trying to save the WPI. And maybe ERV and her ilk. Now all that money that was just raised at Vivant and the WPI annual fund raiser can be spent on lawyers to go after Dr. Mikovits, as they try to continue to lure patients down the yellow brick road. The baby in this divorce? The grants. An institute without a chief scientist and a scientist without a lab.

What’s left? A lab running a bunch of tests that I can order from Quest and LabCorp, for which insurance will pay. A CEO who, when I was there, had six people working for her, including a personal assistant, while Dr. Mikovits had two, and then one. A doctor working for himself. An awful lot of empty space. Less than no respect at the medical school. A post doc. A paper which looks like, one way or another, it will be completely discredited soon with everybody calling everybody a liar. Some GenBank sequences and related patents, which I know very little about, but which I imagine are enough to muddy the waters for everyone else, and therefore prevent work from seeing the light of day. Why would anyone want to get into this mess now? My fear is that the WPI will try to exist without substance to preserve their intellectual property. At this point, the counter on the top of the side bar is counting more lost time.

All this in the context of: I still think a gamma retroviral hypothesis is the best one we have.

Today’s song: Stuck In The Middle With You

Square One

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Breaking news. The entire WPI research program has been closed by the institute’s CEO, and the facility is now locked down. It’s former principle investigator, Dr. Judy Mikovits, is in active discussions concerning institutions to which she may move to continue her grant-funded research. The institutions must remain unidentified, for obvious reasons, but it’s important for patients to know that she remains committed to continuing this critical work.

So now, on top of everything else, a divorce at the WPI. Yet to come are all the things that can happen in such messy situations. Meanwhile, there is no Mikovits-led research at the WPI or any research institution at the moment. An enormous loss of possibility. I’ve done a lot of soul searching about whether to write this blog or not. My motivation for writing all along has been to make things better, to inform, alleviate isolation, share ideas that I hoped would be useful. This is different. Writing this entry, I feel like I’ll be taking away hope, which is anathema to me. But at this time, withholding the information I have would be dishonest. I don’t know what else to do, except tell it the way I see it.

Here is the reality and the context for why I write this particular blog entry: My email inbox is filled with so much pain and confusion, as patients try to figure out what the BWG study means to them. I feel it is my obligation to both these patients and the larger community to share my opinions. I think what the BWG results mean is that all the XMRV/HGRV testing done at VIP Dx has been and is now null and void. Keep in mind that Dr. Mikovits works at the WPI research lab, which is a separate lab from the clinical, commercially-oriented VIP Dx lab. She believes that she has reproduced her original work many times and found evidence of infection in the patients who were previously found XMRV positive. But she never found any single patient positive on every date tested by every assay. So there has been an assumption that there were false negatives in the WPI research lab for some time. Another important thing to keep in mind is that WPI routinely used several tests on each sample, whereas VIP Dx used different, more limited testing, on the samples they received, testing that apparently was never truly validated against WPI methods or performed with appropriate controls. I personally don’t know why this was the case or how it happened. Obviously the decision to sell a test was a very poor one, hindsight being 20/20. It left the institute with a difficult conflict of interest.

I have watched this whole thing unfold and kept quiet because I hoped that management at the WPI would come to their senses, before it was too late. They have not, so I now feel obligated to share what I know.

Dr. Mikovits is a personal friend of mine. We’ve spent time together in Reno. We were excited about our collaboration. We still speak and email regularly. Because I know her so well, I can tell you first hand that she never thinks of or spares herself, and instead gives her all to the research and the patients who need it so badly. She has been criticized for the unorthodox step she took of allowing patients to gain access to her, a step that was life-saving for some, though it turned her into the ME/CFS hotline.

In terms of the BWG: I was told that the BWG specimens were being run in both the WPI research lab and the VIP Dx clinical lab. Though the labs were kept separate, and cooperation between the two labs was already very troubled, Dr. Mikovits believed that VIP Dx would succeed, and everything would be doubly validated.

When the results of the BWG were uncoded and revealed to all nine labs (but not yet made public), in early August, WPI was left in a bad place. Dr. Mikovits says that at that time she asked WPI management to stop offering the XMRV test at VIP Dx. But the testing was not stopped. Why?

Then, when the BWG results were finally made public on September 22, Dr. Mikovits was quoted as saying, “VIPdx lab will NOT continue XMRV-testing because it hasn’t been shown to be reproducible in [the] BloodWorkingGroup”. Shortly after she said this, cooperation between the two labs ceased completely and the research lab was closed. Why?

It is important to know that Dr. Mikovits stands by her work at the WPI research lab, which is all she can vouch for. She cannot account for what happened at VIP Dx. It was in a different location, under different leadership: Dr. Lombardi was in charge at VIP Dx.

Now it appears the WPI research program is getting thrown under the bus, but VIP Dx is still up and running, now minus XMRV testing. None of this means that we don’t have HGRV’s, or that some of the work that came out of the Mikovits-led research lab wasn’t correct. What it does mean is that there is no validated test for clinical, commercial use. And it means we are now at risk of losing all the gains we’ve made because of poor managerial decisions.

My next blog will be to repost Dr. Mikovits’ slides from Ottawa, this time with her comments and a summary from me, making the case for HGRV’s. Culture contamination with VP62 doesn’t explain away her findings. She was finding variants of XMRV. The serology test used in the BWG and published in Lombardi et al is picking up something that is at least very close to, if not antibodies to, MLV proteins. Someone needs to find out what those proteins are. There were electron micrographs from patients showing retroviruses. Pictures. Frank Ruscetti has been studying retroviruses since the beginning of the field and he believes he has been looking at something real. And there have been clinical responses to antiretrovirals, including ours, that are hard to explain away, other than that they are doing what they are supposed to do, inhibiting the replication of retroviruses. Please read Dr. Snyderman’s posts and comments again: A Reason For Hope.

As sometimes happens with divorce, we now find ourselves in a position where we have to take sides. The science, not the institution, is the child that must be protected somehow in the ensuing custody fight.

For the record. As we descend back into darkness… I wrote the below text a few weeks ago, but didn’t post it. I have confronted these issues directly with WPI management and not gotten an adequate response.

Untitled blog:
If you tell the truth, you don’t have to remember anything.
~ Mark Twain

I’ve been quiet about my own personal experiences at the WPI, figuring things would unfold on their own, without disclosure from me. But something is happening that I can’t just let pass, It is this belief patients have that, could they only get to Reno and be treated at WPI, it would all be better. This dynamic is too painful to watch in silence. It hits a nerve. When my daughter got sick with “Chronic Lyme Disease,” I felt that there was information other doctors had that might help her. The memory of that feeling, of being unable to help my child, thinking that there was something to know that I didn’t know, and the poor decisions that desperate feeling led to, is driving this next disclosure of mine. Keep in mind that most of what I know about that is happening on the clinical side at the WPI now is hearsay. He said, she said. Eventually, it will all come out in the wash. But as a physician, I feel the medical carrot being dangled before the public needs comment.

I recently watched Annette Whittemore on Nevada Newsmakers imply that there is new treatment available at the WPI that is producing miraculous results. Due to patient confidences, I can only impart my reaction, not prove my case with details. But her comments were over the top, an advertisement, cobbled together from little pieces of reality, but not reality. There is one doctor working independently in the clinic space, downstairs from the WPI. He is a lovely doctor, an experienced endocrinologist with an interest in CFS. He would have made a wonderful addition to a multidisciplinary team. Does he know something that nobody else knows regarding how to treat CFS? No. There is no treatment being offered in Reno that isn’t mentioned on my blog. No secret knowledge. Nothing you need to be an insider to find out.

It has been really tough for me to decide what, if anything, to say about this next topic. Given that I promised to be truthful here, saying nothing seems almost a lie of omission. If I say something, I sound bitter, which maybe I am. And if I say nothing, I sound incompetent, which I am not. A no win situation. But the truth is, I was well on my way to getting the WPI clinic going as envisioned from day one: A team of like-minded doctors sharing ideas and generating a large patient database, an integral part of a WPI translational research institute. It would have generated enough income to support the research program. But the plug was pulled, inexplicably. A very poor decision.

The ways in which I was mismanaged and completely constrained by ineffective micromanaging when I was working at the WPI, and now this insanity, shutting down the research program, establishes a pattern of behavior. Although it is sad, the party is over, and needs to be. They were, and are, in over their heads. They started with the best of intentions. We will always owe them a debt of gratitude for the spark of genius and the increased awareness they have brought to our disease. But now, the work needs to be done by someone with the resources to do it right. They have risen to their level of incompetence. It doesn’t matter to us who wins, gets the money or what their personalities are like, as long as the research continues. We need it to happen. The WPI is now an obstacle to progress.

Tonight’s song: Square One by Tom Petty

The IgNobel Prize

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I opened an email from Dr. Racaniello’s virology blog, in my wheelchair, at the Phoenix airport Monday morning, after the redeye from Kona:

It was like opening my door and finding a burning cross in the front yard. I was so angry, I was shaking by the time I got on the plane to Albuquerque. Anyone who would engage in such a tasteless joke in order to gloat, at the expense of millions of sick people, has zero credibility as far as I’m concerned. Closed mind. Closed heart. A little man, and I am not referring to his height.

I am writing to the president of Columbia University demanding a public apology to the patient community for this obscenity. I hope you will too.

Columbia University in the City of New York

Office of the President
Lee C. Bollinger
Contact Us
Office of the President
202 Low Library
535 West 116th Street, Mail Code 4309
New York, NY 10027
General Inquiries or To Contact the President 

Phone: (212) 854-9970
Fax: (212) 854-9973
Email: officeofthepresident@columbia.edu

When The Going Gets Tough…

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The intrepid Dr. Mikovits went up against Darth Vader today in Ottawa. In the face of incredible adversity, she took the heat. For us. And she points the way to the next step. Next Generation Sequencing. Here are her slides. Click each to enlarge. May the force be with her. Brava!

A Reason For Hope

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I have something special to share with you, since hope seems in short supply today. One of our own is a clear beacon of light in the fog. Dr. Michael Snyderman’s one man experiment has been presented here before, last in April, clearly showing a prolonged remission of his CLL due to antiretroviral treatment. Since then, he suffered a relapse, while still taking Retrovir (AZT) and Isentress (raltegravir). After carefully documenting the relapse, he added Viread (tenofovir) and here are his stunning results. This is the strongest proof of concept that we have at this time. It is possible he will be ignored, but by all rights, at the end of the day, he should be credited with changing medical history. He has been very brave and very restrained, having done nothing else for his cancer or his CFS, except for antiretrovirals. His leukemia allows for very precise monitoring, but do not forget that he had ME/CFS for many years prior to CLL, and he has experienced clinical improvement of those symptoms as well. It is a game changer, or should be.

click to enlarge

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The parameters are:
  1. ALC. Total lymphocyte count. White blood cell counts (WBC) were determined on a LH 750 Coulter Analyzer. The percentage of lymphocytes was determined with a 200 cell manual differential and the absolute lymphocyte count was determined by multiplication by the WBC. 
  2. CD-19. Total B-cell count. CD19 percentages were determined by flow cytometry and the total count was measured directly.
  3. Trisomy-12 count. Trisomy 12 is a subclone of Dr. Snyderman’s CLL and probably the most aggressive of the CLL clones. The fact that it is also going down is very supportive of the importance of the response. Trisomy 12 percentages were determined by FISH on peripheral blood mononuclear cells and the absolute count was determined by multiplying by the ALC.
  4. γδ (gamma delta) T-cells. This isn’t a cell count, but a quantitative measure of T-cell clonality based on a PCR which detects gene rearrangement.
  5. ZAP 70. Zeta chain associated protein 70, a tyrosine kinase normally expressed by NK and T cells, is required for normal T cell receptor signaling. ZAP 70 is not normally expressed in B lymphocytes, but has been found in a subset of patients with CLL and appears to correlate with survival. Despite the uncertainty concerning normal threshold values, increased levels of ZAP-70 detected by flow cytometry denote a poor prognosis.

From Dr. Snyderman:

The 2nd graph is designed to make just one point. It shows the kinetics of the T-cells compared to the kinetics of the CLL. The importance is enormous. The gamma delta T-cells have never been tracked before. This shows that they can proliferate, not just remain static, but proliferate autonomously, like a neoplasm, albiet a low grade neoplasm.

At least in my case, the clonal gamma delta T- cells cannot be reactive as my plasma is negative for infectious virus; there is nothing there to react against. I hypothesize that rather than just being reactive, the T-cells contain integrated virus and the virus is coding for viral proteins that stimulate cell division and release of cytokines. Because the gamma delta T-cells tend to increase, cytokine levels must be increasing which at least partially explains why CFS patients get sicker and sicker.  Because the cytokines can stimulate cancer, increasing levels of cytokines is one explanation why cancer gets started and then gets worse and worse. Dr. Mikovits is repeating my cytokine signature to prove that the cytokines are back up again.
It looks as though the growth of clonal gamma delta T-cells which are known to make cytokines, coincident with relapse, may have stimulated my leukemia cells to increase. Cytokines are believed to be able to stimulate cancer. This is relevant to CFS because elevated proinflammatory cytokines are part of the reason that CFS patients get sick. Dr. Mikovits said that at the time of my relapse the DERSE cell assay was still negative for infectious virus so the relapse can’t be blamed on viral resistance. It probably represents the clonal gamma delta T-cells being more sensitive to whatever RT leaked through, despite the AZT, and the tenofovir must be able to shut this down. So Gag and Env must not yet be important to my T-cells. When I relapse again, I will test whether Gag and Env have become important, by adding fosamprenavir, which has been shown to inhibit MLV protease. The data suggests that tenofovir is synergistic with AZT and it may be worth considering using the two drugs together in the future to treat XMLV related disorders. Of course this is a one-person study, but as there is nothing unusual about me, it is a rational starting point for further investigation.
The greatly increased risk for B-cell malignancy in CFS may be due to infection of the B-cell line by XMRV’s. Retroviruses have been thought to cause cancer by insertional mutagenisis. This mechanism requires that the retrovirus proviral DNA be integrated into host cell DNA next to a proto-oncogene thereby inducing activation of the proto-oncogene. A more important mechanism with XMRV’s may be the ability of viral proteins to change host cell gene expression. 
Twenty-four to forty-eight hours after a permissive cell line is infected with XMRV, multiple cellular genes are expressed: “10 genes are implicated in cell morphology, 11 genes in cellular development, 12 genes in cell-to-cell signaling and interaction, 11 genes in cellular movement and 13 genes in cellular growth and proliferation” [1]. Spadafaro has shown that reverse transcriptase can cause gene activation and lead to the malignant phenotype [2]. In some retrovirus linked cancers, env [3] and gag [4] may also be important in malignant transformation. 
The finding that a retrovirus did not cause malignant transformation de novo in tissue culture would be irrelevant to the clinical reality of human cancer. It is accepted that multiple events are necessary to convert a cell line into a pre-neoplasm or a clinically important neoplasm. Human cancers have mutated genes and changes in gene expression that could make them permissive to infection by retroviruses. The retroviruses could induce further changes in gene expression that would make the infected cell line behave in a more malignant fashion. The corollary to this is that treatment that would subtract viral influence from a neoplastic cell line could make it behave in a less malignant way. 
A complementary hypothesis is that T-cells are also infected by XMRV’s resulting in a clonal T-cell expansion. The clonal T-cells produce elevated cytokine levels which may be partially responsible for the CFS. Furthermore these cytokines may have a paracrine activity that would stimulate a simultaneous neoplasm to behave in a more aggressive fashion.

Oncology has been focused on the obvious malignancy and cancer is much more complicated than that. No longer can oncology just treat the obvious malignancy. Attention must be paid to treating the clonal T-cells. It goes without saying that the virus also must be treated. We are just looking at gamma delta T-cells now. There may be other clonal expansions that we haven’t looked for yet: clonal alpha beta T-cells, clonal B-cells, clonal monocyte/microglial cells and clonal mesenchymal stem cells. We are just beginning, but at least we are beginning.

1. XMRV infection induces host genes that regulate inflammation and cellular physiology. Lee M, Gusho E, Das Gupta J, Klein E, Silverman R. J Urology 2011, 185(suppl 4):e 113. 
2. Inhibition of endogenous reverse transcriptase antagonizes human tumor growth. Sciamanna I, Landriscina M, Pittoggi C, Quirino M, Mearelli C, Beraldi R, Mattei E, Serafino A, Cassano A, Sinibaldi-Vallebona P, Garaci E, Barone C, Spadafora C. Oncogene 2005, 24:3923–3931. 
3. MMTV Env encodes an ITAM responsible for transformation of mammary epithelial cells in three-dimensional culture. Katz E, Lareef MH, Rassa JC, Grande SM, King LB, Russo J, Ross SR, Mon JG. JEM 2005, 201:431-439. 
4. Sequences within the gag gene of mouse mammary tumor virus needed for mammary gland cell transformation. Swanson I, Jude BJ, Zhang AR, Pucker A, Smith ZE, Golovkina TV. J Virology 2006, 80:3215–3224.

    Random Thoughts Upon Returning To Practice

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    I went down for a while after I wrote the last blog. I was feeling poorly and it was coloring my outlook, so I didn’t want to write anything I’d regret. I’ve been in Kapa’au, on the Big Island, for the last two weeks seeing patients and have felt noticeably better since I arrived. Pretty definite cause and effect. It’ll be interesting to see if it lasts through a third week, when the benefit of the altitude change should be over; this is the first time I’ve stayed so long. I still think that altitude is a major factor for me. My CBC was normal before this trip, for the first time off AZT for 6 months, but also for the first time in years, because my Hct was above reference after my move to Santa Fe, and is now 41, with normal indices.
    When I felt myself dip, I stopped Isentress, because experience has taught me that when things are going south, stop what you can. I was all over the place at the time, but didn’t notice anything I would call better or worse from stopping the drug. As usual with clinical medicine, especially with this disease, there are confounders, so I suppose you could interpret my current upswing as improvement from stopping Isentress, but I really doubt it. I think that it did something at the beginning (but certainly can’t prove it), and then was doing nothing. One of the interesting things that is emerging anecdotally is that the assumption, born from the experience of HIV, that if the drugs work they must be taken forever, could be incorrect for us. There are reports of patients improving from arv’s, going off for one reason or another, and holding the improvement, or even improving further. It is a relapsing remitting illness. Maybe the drugs can induce latency, which can be maintained in other ways. I remain on Viread, considering what is next. Of note is that a few people have improved on arv’s other than the three that Singh found inhibited VP62.
    Here are some cautions about the use of arv’s for ME/CFS, information gathered from our intrepid trail blazers. There are two patients who have had renal function elevation from tenofovir. One discontinued and one reduced to half dose, with return to baseline renal function, but isn’t doing as well clinically as before on the full dose. My understanding is that HIV patients without preexisting renal disease aren’t expected to have this problem, so more frequent monitoring is a good idea for CFS patients. When tenofovir goes bad for HIV patients, it causes a renal mitochondropathy and our mitochrondrial function is already problematic, so we may be more sensitive, as we are to drugs in general. We were checking safety labs every three months and have upped it to every two.
    Arv’s cause a “herx”, or cytokine flare, for most. I have heard of one patient who flared with arv’s, took them only briefly (no AZT), stopped them in April and is still worse than before, at a lower level of function, though seems to be slowly returning to baseline. She says she went into it with her eyes wide open. We all owe her a debt of gratitude.

    My impression is that patients who have had other problems addressed first have an easier time of it, and are more likely to respond. So far, I have not prescribed arv’s, not because I’m unwilling, but because there are other things that are more pressing that need to be addressed now. Neglect and/or the indiscriminate use of dangerous drugs characterize the care most have had to date. 

    My early practice impressions support what I have learned from my email and taking medical information calls for the WPI. We have been incredibly neglected. Doctors hear CFS and they forget everything they do know. They don’t do the regular things. If a healthy woman walks into a doctor’s office complaining of tachycardia and palpitations, with hyperlipidemia and borderline adult onset diabetes, family history of coronary disease, they might worry about it a little, get an EKG, treadmill, maybe try a few things. If a CFS woman walks in, she gets nothing. Doctor goes brain dead. They don’t get it that in addition to our weird symptoms, we get the usual things, sooner and worse. 
    The patients I am seeing are remarkably homogeneous. Clinically however, the money is going to be in the differences, looking at the way the disease has progressed in each person, where the vulnerabilities are, and what can be tipped in the patient’s favor. The most common possible intervention, likely to impact quality of life (besides stopping meds) is hormone replacement/balancing. In my last practice, in addition to other things, I did a lot of weaning patients from meds, with the support of neurofeedback, and also, hormone balancing, for women like myself, who were having a terrible perimenopause, after a normal menstrual and reproductive history. They were mostly in their 40’s. In this practice, I am seeing women who need the same thing, but they are in their 20’s. What was PMS for my generation is now PCOS for the next generation. And men have the same hormone problems, depletion and receptor insensitivity. 
    Bioidentical hormone replacement means using preparations that provide the body with the same molecule it makes on its own. In conventional practice, most doctors use synthetic hormone-like drugs, Prempro, for example, or birth control pills for young women. The Pre is Premarin, which stands for pregnant mare urine; it is a lot like human estrogen, but not the same. The Pro is Provera, a progesterone-like drug, probably responsible for the increased cardiovascular risk found in the Women’s Health Initiative, that killed HRT for the average woman. Bioidentical hormones have never been seriously studied, and probably never will be, because they are naturally occurring substances and therefore, not patentable.
    I am seeing families, husband/wife, mother/daughter; there is a CFS mother/autistic son scheduled for next trip. We are making progress on the family survey, though it isn’t quick, very labor intensive. Everyone helping is sick and we have no funding. Down and dirty… it can take more than 20 years for a spouse to get sick. Kids go down much earlier than their mothers did and are much sicker. If you have CFS, your chances of having an autistic first degree relative is very high. Real numbers forthcoming…
    Yesterday – Ali’s newest FaceBook picture 
    Ali is doing fantastically well. Her MCS symptoms have mostly resolved, to the point that she can get out again and be in places where there are chemical smells, like the hair dresser and the lab. Oxygen has been huge for her. She uses oxygen at 10L/min by non-rebreather mask for about an hour a day. She does it without prompting and she uses it for rescue if she does feel sick. We have it set up with the concentrator in the middle of the house and a long hose that goes anywhere. Then you don’t have to listen to the noise it makes. She tried the chamber once, felt sick from the pressurization, didn’t finish a full treatment and has declined to use it since. She says it is unnecessary, since she is doing so well. I have been using the chamber irregularly, partly because of all the travel. Normobaric oxygen is helpful for me, but a chamber treatment is clearly better. The problem is I don’t do it, because I’m not a great patient:). It’s much easier to use the concentrator alone. Being able to just grab the mask is wonderful, because it’s something immediate that you can do for yourself. It helps me within 10 minutes when I really dip.
    Options for trying oxygen? It comes in big tanks that are inexpensive (~ $20/tank), but at high flows, a tank doesn’t last long. Insurance will sometimes cover oxygen for migraines, otherwise, in most areas you can find an oxygen supply company that will rent you a concentrator for about $200/month. Often they only have ones that go to 6L. The delivery device needs to be matched to the flow rates. A cannula can go up to 6L/min (FiO2, or inspired fraction of oxygen, 24-40%, instead of 21% room air), but is really comfortable only at 2L/min. You can go to 6L/min with a mask (FiO2 up to 50%). A non-rebreather mask has a reservoir that holds the oxygen with a one way valve that lets it come in to the mask with inhalation. There are also valves on the side of the mask that let the exhaled gases out, including CO2. A non-rebreather mask requires a flow rate of at least 10L/minute and gets 60-90% depending on fit. Concentrators are sometimes available used, after people die. They should be serviced before use.
    The only absolute contraindication for hyperbaric (not oxygen alone) is the presence of a pneumothorax. Other contraindications are hereditary spherocytosis, prior treatment with bleomycin or cisplatinum, concurrent treatment with disulfiram, doxorubicin or sulfamylon. Relative contraindications, or conditions requiring close monitoring are problems clearing ears, asthma or anything causing air trapping, and epilepsy or high fever, because high dose oxygen lowers seizure threshold. Pacemakers and implanted pumps should be cleared with the manufacturer. High dose oxygen may accelerate the maturation of cataracts, but isn’t thought to cause them de novo. A disclaimer, like on a drug commercial:).
    I receive mail from people who have asked their doctors to prescribe oxygen for them and been told it’s too dangerous. Please ask them why they think so. Doctors have a visceral fear of oxygen and are not knowledgable with respect to its use. They were taught about COPD and hypoxic drive; COPDer’s who retain CO2 at baseline, in crisis can become obtunded and decompensate further, if given high dose oxygen. Practically speaking, by the time that happens, they are probably going to need intubation anyway, and in reality, even those patients tolerate oxygen just fine when they are not in trouble. I treated people with COPD and CO2 retention with HBOT for brain injury, 1.5 ATA 100% O2 delivered by hood for an hour in a multiplace chamber with attendant present, for 40+ treatments, without problems. 
    We have continued Ali’s modified Meyer’s cocktail (containing Leucovorin 10mg), followed by a glutathione push. She gets a clear lift from the infusions lasting a week or two. She comes to me when she wants one. Because I was going to be away this time for three weeks, she started oral folinic acid 800 mcg daily, then increased to 1600 mcg, and she has continued uphill in my absence.

    Oxygen and folic acid derivatives seem worth a try for pretty much everybody with ME/CFS, except perhaps, if there’s a history of cancer also, further consideration is warranted. Deplin (prescription high dose L-methylfolate), folinic acid, 5-MTHF. Side effects are limited to overactivation/sleep disruption, and are dose related. However, for every intervention, no matter how benign, there seems to be someone who has been made worse by it… Folic acid derivatives should be taken with B-complex and extra B-12. A few people get overactivated with too much B-12, so, as always, it is a good idea to start things one at a time, and if that happens, maybe try again another time at a lower dose.

    I have been deeply touched by the many expressions of concern I have received from readers during my short writing hiatus. It is amazing to me that so many people I’ve never met aren’t strangers, but friends sharing a common experience. So here we are, together again, waiting to see what will unfold in Ottawa.

    Exciting news from Dr. Snyderman coming soon…