Provocation Testing in CFS/ME James N. Baraniuk, MD Georgetown University, Washington DC USA

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1 from: Vivienne Hughes to: GUmail date: Sun, Sep 16, 2018 at 11:03 PM subject: Re: PP-Baraniuk mailed-by: griffith.edu.au Provocation Testing in CFS/ME James N. Baraniuk, MD Georgetown University, Washington DC USA

2 Provocation Testing in CFS/ME James N. Baraniuk, MD Georgetown University, Washington DC USA

3 Hypothesis: Provocation Testing in CFS/ME Baseline symptoms, cognitive and other functions are relatively similar to normal when CFS/ME subjects are well rested. It is necessary to use provocation methods to perturb body systems and induce subjective and objective evidence of dysfunction in CFS/ME compared to control subjects. Null Hypothesis 1: There are no differences between CFS/ME and control subjects. Null Hypothesis 2: There are substantial differences between CFS/ME and control subjects at all times that can be detected without provocations that worsen symptoms or cause exacerbations.

4 Georgetown University Telephone screening for 1994 CDC Fukuda criteria CFS/ME subjects 2000 Kansas criteria Gulf War Illness (GWI) Control subjects for sedentary activity status, and Exclude major medical and psychiatric diseases. All subjects complete online questionnaires to assess: Baseline Fatigue Somatic symptoms Pain Interoception Psychological symptoms Quality Of Life

5 Clinical Research Unit on Day 1 Scripted history and physical examination Routine blood work Serial blood work (pre-exercise baseline) Dolorimetry systemic hyperalgesia = tenderness Heart Rate Variability EKG Vital signs during recumbent and standing postures

6 Chronic Multisymptom Illness (CMI) 2 Musculoskeletal Fatigue Cognition, Mood Defining CFS and its Differential Diagnosis GWI Kansas 3 Pain Fatigue, Sleep Cognition, Mood Neurological Gastrointestinal Respiratory Skin CFS Fukuda 4 FM FM 2011?? FM Myalgia Arthralgia Widespread Pain Widespread Pain Fatigue Fatigue Fatigue Sleep Waking Waking unrefreshed unrefreshed Post-exertional malaise Cognition Cognition Cognition Depressed Headache Headache Sore throat Sore lymph nodes Somatic symptoms Abdominal pain Tenderness Widespread Pain 1 chronic symptom in 2 categories 3 of 6 categories Fatigue plus 4 of 8 Severity scores Severity scores Pain + Tenderness

7 Chronic Multisymptom Illness (CMI) 2 Musculoskeletal Fatigue Cognition, Mood Defining CFS and its Differential Diagnosis GWI Kansas 3 Pain Fatigue, Sleep Cognition, Mood Neurological Gastrointestinal Respiratory Skin CFS Fukuda 4 FM FM 2011?? FM Myalgia Arthralgia Widespread Pain Widespread Pain Fatigue Fatigue Fatigue Sleep Waking Waking unrefreshed unrefreshed Post-exertional malaise Cognition Cognition Cognition Depressed Headache Headache Sore throat Sore lymph nodes Somatic symptoms Abdominal pain Tenderness Widespread Pain 1 chronic symptom in 2 categories 3 of 6 categories Fatigue plus 4 of 8 Severity scores Severity scores Pain + Tenderness

8 Chronic Multisymptom Illness (CMI) 2 Musculoskeletal Fatigue Cognition, Mood Defining CFS and its Differential Diagnosis GWI Kansas 3 Pain Fatigue, Sleep Cognition, Mood Neurological Gastrointestinal Respiratory Skin CFS Fukuda 4 FM FM 2011?? FM Myalgia Arthralgia Widespread Pain Widespread Pain Fatigue Fatigue Fatigue Sleep Waking Waking unrefreshed unrefreshed Post-exertional malaise Cognition Cognition Cognition Depressed Headache Headache Sore throat Sore lymph nodes Somatic symptoms Abdominal pain Tenderness Widespread Pain 1 chronic symptom in 2 categories 3 of 6 categories Fatigue plus 4 of 8 Severity scores Severity scores Pain + Tenderness

9 Center for Epidemiological Studies Depression (CESD) 20 items scored 0 to 3 by severity in past week Cut-off score 16 / 60 This threshold has a 30% false positive rate [Vilagut, 2016] Sensitivity = 87% Specificity = 70% CESD remains the gold standard for epidemiological studies that screen populations and countries for risk of depression Factor Analysis: Somatic, Depressed, Anhedonia, Interpersonal Somatic = Fatigue, Sleep, Cognition, Effort, Bother, Talk less, Appetite The 4 factor scores have never been evaluated in depression or control groups There was a strong relationship between the symptoms of depression as measured by the Center for Epidemiologic Studies-Depression Scale (CES-D) and fatigue, but fatigue was neither sensitive nor specific for the diagnosis of depression. Fuhrer R, Wessely S. The epidemiology of fatigue and depression: a French primary-care study. Psychol Med Sep;25(5): Review. PubMed PMID:

10 Center for Epidemiological Studies Depression (CESD) 4 Factors: Somatic, Depressed, Anhedonia, Interpersonal Median 24% of US population at risk for depression using total score (black) threshold of 16 / 60 (NHANES & sedentary controls) Traditional threshold for Total CESD Score (black) = Depression Score of 16 / 60 = 24%

11 Center for Epidemiological Studies Depression (CESD) 4 Factors: Somatic, Depressed, Anhedonia, Interpersonal Depression Total CESD Score (black) threshold of 16 / 60 94% of Depressed subjects in PROMIS studies 16 / 60

12 Center for Epidemiological Studies Depression (CESD) 4 Factors: Somatic, Depressed, Anhedonia, Interpersonal SC CFS GWI Depressed Depressed High Somatic Domain Scores cause positive CESD in 54% of CFS

13 Center for Epidemiological Studies Depression (CESD) 4 Factors: Threshold score is too low 16/60 20% false positive Somatic High somatic scores drive CESD and depression in CFS Depressed Present in CFS but does not drive CESD score Anhedonia Present in CFS but does not drive CESD score Interpersonal

14 Frequency Sensitivity Systemic Hyperalgesia in CFS, GWI and FM Females H&P CFS (green, n=174), GWI (red, n=68), Control (black, n=133) Pain + Tenderness Fibromyalgia (1990) (yellow, n=28) Dolorimetry Method: Apply pressure with dolorimeter at 18 traditional FM tender points Determine pressure that causes pain Average kg Frequency distributions 40% 30% GWI n=68 CFS n=174 FM n=28 SC n= kg % 10% 0% Dolorimetry (bins of 1 kg) Specificity GWI CFS

15 MRI - Exercise Study to Model Exertional Exhaustion Q H&P MRI DAY 1 DAY 2 MRI LP HYPOTHESES: 1. CFS have depression 2. CFS have tenderness (systemic hyperalgesia) 3. Submaximal exercise on DAY 1 reduced VO2 on DAY 2 4. Submaximal exercise on DAY 1 postural tachycardia in 1/3 rd 5. Exercise worsens orthostatic intolerance 6. MRI before exercise on DAY 1 will show good brain function MRI after exercise on DAY 2 will show bad brain function 7. Cerebrospinal fluid contains CFS biomarkers

16 MRI - Exercise Study to Model Exertional Exhaustion Q H&P MRI DAY 1 DAY 2 MRI LP Ceiling vs Floor Effects Functional Disorders Migraine MRI: 3T Seimens TrimTrio, 32 element head coil, new PRISMA Brain anatomy voxel based morphometry Molecular spectroscopy Resting state scan for Resting State Networks Cognitive Task n-back working memory task Attention = 0-back = See a letter. Press a button. Working memory = 2-back = See a string of letters Submaximal test: Does exercise on Day 1 cause a decrease in exercise on DAY 2? Brain biomarkers

17 MRI - Exercise Study to Model Exertional Exhaustion Q H&P MRI DAY 1 DAY 2 MRI LP Background: GWI Submaximal exercise on DAY 1 postural tachycardia in 1/3rd Stress Test Activated Reversible Tachycardia = START = 25% No postural tachycardia before exercise Postural tachycardia after exercise 2 time points with ΔHR 30 bpm after exercise ΔHR = Standing Recumbent No ΔHR = STOPP = 62% of CFS POTS = 13% of CFS = GWI = Control = Literature Standing Up

18 Orthostatic Problems Orthostatic Intolerance Symptoms Dizziness, Lightheaded Orthostatic Instability Change in heart rate with posture Change in autonomic tone Vagal Parasympathetic to slow down the heart Sympathetic to speed up the heart Results are biased from Heads Up Tilt Table testing High false positive rate Not physiological

19 Dizziness Before Exercise Control CFS Recumbent Standing Recumbent Standing CFS had significantly more Dizziness than Controls while supine and standing. Dizziness Score > 2/20 reported in 9/25 Controls and 33/39 CFS (FET, p<0.0001). 10% vs. 85%

Dizziness After Exercise Postural Orthostatic Tachycardia Exercise-Induced Postural Tachycardia Postural Orthostatic Tachycardia Exercise-Induced Postural

20 Dizziness After Exercise Postural Orthostatic Tachycardia Exercise-Induced Postural Tachycardia Postural Orthostatic Tachycardia Exercise-Induced Postural Tachycardia Exercise increased Dizziness in 22/39 CFS POTS did not explain Dizziness in CFS Exercise caused symptoms that could not be explained by postural tachycardia

Intolerance (No OI) = 28% Postural Orthostatic Intolerance = Standing = 31% Persistent Orthostatic Intolerance =

21 Dizziness After Exercise POTS did not explain Dizziness before exercise Postural Tachycardia did not explain the increased Dizziness after exercise (85%) Receiver Operating Characteristics defined Dizziness > 2 / 20 No Orthostatic Intolerance (No OI) = 28% Postural Orthostatic Intolerance = Standing = 31% Persistent Orthostatic Intolerance = Recumbent & Standing = 41% Recumbent Standing Control CFS Dizziness While Lying Down in 41% CFS Exercise increased Dizziness in 22/39 CFS (56%)

22 Recumbent Dizziness in CFS Recumbent Dizziness in CFS in 41% Persistent Orthostatic Intolerance (symptoms) Dizziness gets worse in 85% of CFS Component of Post-Exertional Malaise? Dizziness is not related to postural tachycardia Orthostatic instability (heart rate) Postural tachycardia is related to decreased parasympathetic tone Decreased vagal messages from the brain stem allow the heart to speed up NULL HYPOTHESIS: Autonomic dysfunction (orthostatic instability) is not the cause of dizziness and orthostatic intolerance HYPOTHESIS: It is all in your head (Vestibular, Brain stem, other?)

23 MRI - Exercise Study to Model Exertional Exhaustion Q H&P MRI DAY 1 DAY 2 MRI LP HYPOTHESES: 1. CFS have depression 2. CFS have tenderness (systemic hyperalgesia) 3. Submaximal exercise on DAY 1 reduced VO2 on DAY 2 4. Submaximal exercise on DAY 1 postural tachycardia in 1/3 rd of CFS 5. Exercise worsens orthostatic intolerance (symptoms) 6. MRI before exercise on DAY 1 will show good brain function MRI after exercise on DAY 2 will show bad brain function

24 MRI - Exercise Study to Model Exertional Exhaustion Q H&P MRI DAY 1 DAY 2 MRI LP HYPOTHESES: 1. CFS have depression 2. CFS have tenderness (systemic hyperalgesia) 3. Submaximal exercise on DAY 1 reduced VO2 on DAY 2 4. Submaximal exercise on DAY 1 postural tachycardia in 1/3 rd 5. Exercise worsens orthostatic intolerance 6. MRI before exercise on DAY 1 will show good brain function MRI after exercise on DAY 2 will show bad brain function 7. Cerebrospinal fluid contains CFS biomarkers

25 Cerebrospinal Fluid for Cytokines

None identified in databases or by hand sequencing Pearson Correlations Positive Mode

26 Cerebrospinal Fluid for Metabolomics Untargeted Discovery 17 positive mode and 22 negative mode peaks between sedentary control, CFS and GWI groups at Nonexercise and Post-Exercise None identified in databases or by hand sequencing Pearson Correlations Positive Mode Negative Mode Targeted Biocrates 180 analytes 2 significantly different C5-OH (C3-DC-M) PC ae C44:4

27 Unknowns in LC-MS-MS Positive Mode: Pooled Nonexercise (white) vs. Post-exercise (grey) Mean ± SD Acrolein suspected Positive 456 sec 18 Negative Mode Peaks at 249 sec e.g. M460T249nm Distinguish CFS from GWI in Nonexercise specimens

28 No exercise Targeted Metabolomics Control Post-exercise Control Exercise CFS GWI START GWI GWI STOPP

29 Lumbar Puncture Cerebrospinal fluid mirna DNA genome & genes pre-mrna mirnas fine tune protein expression Mature mrna Spliceosome & Processing Mature mrna mirna ~22 ntd mirna In general, mirnas were reduced after exercise Translate mrna into protein mirna binds mrna mrna destroyed No protein

30 Lumbar Puncture Cerebrospinal fluid mirna DIANA for gene targets No Exercise sc0 = sedentary controls cfs0 = CFS no exercise gwi0 = GWI with no exercise sc0>sc SC>sc0 gwi0>cfs0 gwi0>start START>gwi0 gwi0>stopp cfs0>cfs 33 targets 224 targets targets? 23 targets 36 targets 48 targets 61 targets mir-328 mir-608 mir-425-3p mir-30d-5p mir-204-5p mir-1180 Post Exercise After DAY2 Exericse SC = sedentary controls CFS = CFS START = GWI Stress Test Activated Reverisible Tachycardia STOPP = GWI Stress Test Originated Phantom Perception mir-328 mir-608 mir-200a-5p mir-93-3p let-7i-5p mir-425-3p mir-328 mir-608 mir-200a-5p mir-93-3p let-7i-5p In general, mirnas were equivalent within No Exercise and Post-Exercise specimens mirnas were higher before exercise and (cfs0>cfs, gwi0>start, gwi0>stopp) [except for sc0>sc and SC>sc0] mir-328 mir-608 mir-200a-5p mir-93-3p mir-92a-3p

31 Combinations of mirnas DIANA Intersection of Pathways Weighted Targets # GO Category p-value Genes # mirna 1 nucleoplasm (GO: ) 8.19E ribonucleoprotein complex (GO: ) 3 organelle (GO: ) mitotic cell cycle (GO: ) cytosol (GO: ) cellular component assembly (GO: ) 7 gene expression (GO: ) RNA binding (GO: ) cellular nitrogen compound metabolic process (GO: ) 10 exoribonuclease activity, producing 5'-phosphomonoesters (GO: ) 11 cytoplasmic ribonucleoprotein granule (GO: ) 12 DNA replication initiation (GO: ) 13 ATP-dependent chromatin remodeling (GO: ) # KEGG pathway p-value # genes # mirna 1 Fatty acid 3.12E biosynthesis (hsa00061) 2 Fatty acid 2.46E metabolism (hsa01212) 3 Adherens junction (hsa04520) Lysine degradation (hsa00310) Transcriptional misregulation in cancer (hsa05202) 6 Viral myocarditis (hsa05416) Cell cycle (hsa04110)

Ingenuity Pathway Analysis (IPA) Cytoscape modules # Modules of target proteins with linkers Top pathway for each module Cy0 ACTB, CDC42, ELK4, FASN, FYN, IGF1R, IQGAP1, PTPRJ, SETD7, ZNF703 Adherens

32 Ingenuity Pathway Analysis (IPA) Cytoscape modules # Modules of target proteins with linkers Top pathway for each module Cy0 ACTB, CDC42, ELK4, FASN, FYN, IGF1R, IQGAP1, PTPRJ, SETD7, ZNF703 Adherens junction (Linkers: CCT8, CSNK2A2, CTNNB1, MAPK3, STAT3) Cy1 BAG6, DYRK1A, EWSR1, H3F3B, KMT2D, SCD, SIN3A Transcriptional misregulation in cancer (Linkers: EP300, HIST1H4A, RXRA) Cy2 DDX5, HNRNPC, NCL, PCBP2, PRPF8, SCARB2, TCF3 (Linker: HSPA8) Processing of Capped Intron-Containing PremRNA (Reactome) Cy3 ASH1L, DCP2, DYNC1H1, SPOPL, TGFBR1, (Linkers: SUFU, UBC) Beta5 beta6 beta7 and beta8 integrin cell surface interactions (NCI PID) Cy4 CCND2, CCNE2, MCM7, RB1 Cell cycle (KEGG) mirna DIANA target genes pathways plausible druggable targets and drugs

33 MRI - Exercise Study to Model Exertional Exhaustion Q H&P MRI DAY 1 DAY 2 MRI LP HYPOTHESES: 1. CFS have depression 2. CFS have tenderness (systemic hyperalgesia) 3. Submaximal exercise on DAY 1 reduced VO2 on DAY 2 4. Submaximal exercise on DAY 1 postural tachycardia in 1/3 rd of CFS 5. Exercise worsens orthostatic intolerance 6. MRI before exercise on DAY 1 will show good brain function MRI after exercise on DAY 2 will show bad brain function 7. Cerebrospinal fluid will contain CFS biomarkers

34 Provocation Testing in CFS/ME Common Data Elements to share data between sites Evidence-based definitions for CFS, ME, SEID, GWI, FM, depression Systemic hyperalgesia in CFS and GWI Post-Exertional Malaise / Exertional Exhaustion Model reveals pathophysiological changes induced by exertion Unclear if VO2max is changed or diagnostic Orthostatic Intolerance (symptoms) vs. Orthostatic Instability (HR) Recumbent Dizziness Persistent Orthostatic Intolerance Exercise makes orthostatic symptoms worse POTS and START (ΔHR) are not relevant to symptoms in the broad group of CFS Cerebrospinal Fluid Metabolomics analytes are significantly changed but not identified mirna Informatics Infer pathways Mechanisms?

35 Thank you for the invitation, opportunity, and fellowship James N. Baraniuk MD Georgetown University, Washington DC

CFS/ME. Dr.R.Arulnanthy 03/08/09 BMJ 2007/Nice Guidance

CFS/ME. Dr.R.Arulnanthy 03/08/09 BMJ 2007/Nice Guidance CFS/ME Dr.R.Arulnanthy 03/08/09 BMJ 2007/Nice Guidance CFS Anonymous FACTS Chronic fatigue syndrome is three times more prevalent in women than in men and is most common in younger adults, with 90% of