1. Patients launch a $1.27 million crowdfunding campaign for ME/CFS gut microbiome study.
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Part 2: Brain Cells Making us Sick? Messed up microglia could be driving symptoms
Simon McGrath looks at theories that microglia, the brain's immune cells, might be overactive and driving the symptoms of ME/CFS and fibromyalgia.
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Transcript - Dr. Jason's Webinar, April 14th

Discussion in 'Action Alerts and Advocacy' started by jspotila, Apr 19, 2010.

  1. jspotila

    jspotila Senior Member

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    Several people expressed interest in a transcript of Dr. Jason's webinar on defining CFS. You can access slides and the video on the CFIDS Association website: http://cfids.org/webinar/series2010.asp

    OverTheHills has offered to help transcribe the talk. I'll chip away at it as well. If you want to volunteer your energy to help out, just post here so we can avoid duplication of effort.
  2. Otis

    Otis Señor Mumbler

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    Thank you Jennie. The webinars are a positive thing and having access to replays and slides is great. Not to mention all of the work people put into transcribing them which for me is a really good way to really absorb the webinar.
  3. jspotila

    jspotila Senior Member

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    My pleasure, Otis. I always process info better if I can refer to it in written form.
  4. OverTheHills

    OverTheHills

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    Dr Jason part 1 - 9:25 - 17:10

    Slide 1:
    Dr Leonard Jason

    Professor of Psychology at DePaul University, Chicago

    Director of Community Research Centre

    Appointee of CFS Advisory Committee

    Kim introduces Dr Leonard Jason (who is not a clinician) as a very prolific publisher on CFS/ME, involved in prevalence work, former vice president of IAFCS, advisory committee, has been involved with CAA including physician education. He is also active in research on alcohol and substance abuse.

    Dr Jason begins his presentation at 9:25 into recording
    I appreciate the opportunity to share with this audience some of my thoughts on about the current Chronic Fatigue Syndrome Case Definition. I will refer to this [condition] as ME/CFS, and ME refers to myalgic encephalomyelitis.

    This is a very exciting time for our field, as major discoveries are occurring in a number of critical areas, that are helping us better understand the etiology and pathophysiology of this illness. However I firmly believe that and hope to show during this presentation that our current Case Definition could be a major impediment to replicating findings across different laboratories. For if investigators select samples of patients who are different on fundamental aspects of this illness, because of ambiguities with our Case Definition, then it will be exceedingly difficult for investigators to consistently identify biomarkers.
    And this could lead to more psychogenic explanations of this illness. I hope during this presentation to expand on these ideas .

    [Dr Jason explains that occasionally we may hear an El rumbling by his office in De Paul in fact I heard nothing significant on the webinar or recording].

    Slide 2 pyramid of playing cards

    As you can see on this slide there is a stack of playing cards and it makes a pyramid. Now if the foundation, or the first level of these playing cards is not sturdy, for those of you who have tried to make a pyramid, then the middle and upper layers are vulnerable to collapsing. A sturdy foundation is required for any progress to be made, and really all science works like this. The Case Definition is the foundation for any scientific endeavour, as well as our particular field. A Case Definition is a set of rules that allows investigators and clinicians to determine who has and who does not have an illness. If we cannot do this diagnostic activity in a reliable way all progress in a scientific area will be shaky and vulnerable to collapse.

    Slide 3
    As I said on the last slide, Case Definitions determine who has and who does not have an illness this activity has enormous influence on estimates of how many people have an illness. If a Case Definition selects too few people then prevalence estimates are inappropriately low and less resources and attention will be devoted to that illness. On the other hand if Case Definitions select too many people, in particular people who do not have the illness, it will be difficult to identify biomarkers. Case Definitions are also critically important in identifying viruses, or even a retrovirus, that might be implicated in etiology of ME/CFS. You see, if scientists select widely varying individuals as having ME/CFS, and in particular if some of those individuals do not even have the illness, identification of biomarkers will be compromised, as Im sure you all recognise.

    Finally, even our treatments are strongly affected by our Case Definitions for example if our Case Definition inappropriately selects some individuals who have psychiatric illnesses and then treatments are provided that cure those psychiatric problems investigators could mistakenly conclude that the illness is psychiatrically mediated. And this possibly has occurred in our field.

    Slide 4
    On this next slide one has a Venn diagram, a circle, and this will help explain some of the confusion about ME/CFS Case Definition. And that is because fatigue is experienced at any one time by about 25% of the population so thats about 1 out of 4 people, if you walked up to them and said are you feeling fatigued they would say they are. The other 75% of the population feel fatigued after strenuous activity, thats the majority. So everyone feels fatigue at some point but for most, the fatigue goes away completely when people rest. So heres the problem: everybody else experiences fatigue and then gets over it. So its not unusual for medical personnel and family members of patients with ME/CFS to say Weve experienced fatigue and were able to recover, why cant you? Many inappropriately at this point conclude that this illness must be psychological and as you probably know, the name chronic fatigue syndrome trivialises the seriousness of this illness and further compounds the problem. In a sense its like saying that a person with bronchitis or emphysema had chronic cough syndrome.

    Slide 5
    About 4-5% of the population has chronic fatigue, and that means that they have had at least six months or more of fatigue. In other words about 1 out of every 20 people have six or more months of fatigue and this makes chronic fatigue one of the more common chronic problems affecting our nation. So the question is, among these people, this particular 4% here, the key question is how many have ME/CFS, and this is the issue that the Case Definition attempts to solve.

    Slide 6

    There are a number of reasons people might experience chronic fatigue, for example a medical illness, like cancer, can cause fatigue so this circle here [on the lower right]is people who have a medical illness and this is chronic fatigue, so you can see a certain amount of chronic fatigue is caused by medical illness. Also an affective disorder, such as melancholic depression can also cause a person to be chronically fatigued. So people who have depression would be this circle[lower left], and you can see chronic fatigue is this red circle [lower central circle]so these people have depression that could very well be influencing their chronic fatigue.

    17:10
  5. OverTheHills

    OverTheHills

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    I'd be grateful if someone more techy than I am can tell me how to insert slides at the right point - I've tried print screen screen shots, and couldn't get that to work. Difficult for people to follow without the Venn Diagrams!

    ALso I will take 17:10 to 25:00 next if Jennie hasn't started it yet.
  6. jspotila

    jspotila Senior Member

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    I have not started, OTH. I'll pick up at 25:00 tomorrow. Thank you!
  7. jspotila

    jspotila Senior Member

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    In addition, in our fast-paced technological society some people are overworked and overstressed. And this could be a reason they feel six or more months of fatigue. So this is this group here (top circle). This group is overworked, over-stressed could certainly be causing this fatigue. It could be explaining this proportion of fatigue (overlap of top circle and red circle). Yet these people who are over-stressed and overworked, if they took a vacation and rested they would no longer feel fatigued. It’s easy to see that there are many reasons for a person feeling chronically fatigued and yet here is where the diagnostic confusion occurs. These individuals do not have ME/CFS, and if we inappropriately bring these individuals into our case definition, our studies of etiology and pathophysiology will be based on mixtures of samples in which some have ME/CFS and some have different illnesses or conditions. So we’re going to go through this point again and again in this presentation because it is such an important one.

    Slide 7

    On this slide you see the international case definition. The eight core symptoms are on the slide. [sic] In 1988, investigators at the CDC took an illness that had been called myalgic encephamyelitis by Ramsay and others in Great Britain and renamed it chronic fatigue syndrome. Now in 1994, a major revision occurred and this is called the Fukuda criteria because Fukuda was the first author of the paper describing the revised criteria. So we’re going to be talking primarily in this presentation about these particular criteria, so we’ll call them the Fukuda and other 1994 criteria. And as you can see, to meet the case definition a person would need to have six or more months of chronic fatigue and four out of eight core symptoms.

    Slide 8

    These eight core symptoms are actually on this slide. But here is the conceptual problem: we know that three of the critical symptoms of ME/CFS are unrefreshing sleep, post-exertional malaise lasting more than 24 hours, and persistent or recurring impairment in short term memory or concentration, and these in red are the critical symptoms. But these three symptoms are not required of everybody. In other words, if we have core fundamental symptoms that patients with CFS almost always have, but with the Fukuda criteria, a person could have none of these symptoms and still meet the case definition. Hard to believe, but that’s the case. Let me give a concrete example of what this could do for investigators. Say there’s two studies going on in different parts of the country and one investigator selected patients who had these three core symptoms: unrefreshing sleep, post-exertional malaise, and impairment in short term memory or concentration. So one group had these three symptoms plus headaches, so they met criteria; they had four symptoms. And the other investigator selected patients who only had these symptoms up here (points to first five bullet points) and none of the core symptoms. These two laboratories would have an individual who met the criteria for CFS but they’re very different. It’s like comparing apples and oranges and ultimately, replicating the findings from one lab to the other would be close to impossible if the basic symptoms of these two groups differed that prominently.

    Slide 9

    Here we have some fancy terms: “polythetic criteria.” What it means is that scientists who developed the Fukuda case definition in 1994 allowed researchers and clinicians to select four out of eight symptoms That’s what polythetic means. So you have a choice of four out of eight, rather than saying you have to have these core symptoms. So if you have a choice, that’s the way the Fukuda criteria was developed but they could have done it differently. They could have said these are basic symptoms. They could have said that a critical symptom is, for example, post-exertional malaise and they would say that you have to have it. But they didn’t say that. Is it not possible that it would be more methodologically sound to require such symptoms in the identification of patients? We’ll come back to this issue.

    Slide 10

    Let’s give another example of the types of problems that the current case definition might encounter. One of the more prevalent psychiatric conditions is Major Depressive Disorder. And many people with this psychiatric condition have chronic fatigue and four Fukuda symptoms such as unrefreshing sleep, joint pain, muscle pain, and impairment in concentration. But Major Depressive Disorder and ME/CFS are two distinct disorders. Let me just emphasize, they can be overlapped - some people with ME/CFS might certainly have a Major Depressive Disorder - but there is pure Major Depressive Disorder and there is ME/CFS which does not have major depressive disorder. And most people with ME/CFS have, for example, the types of physical exertion, night sweats, sore throats, swollen lymph nodes. People with Major Depressive Disorder do not have those. Illness onset with ME/CFS often occurs over a few days or even a few hours. With primary depression generally it’s a gradual onset. So the question is whether some research groups studying ME/CFS have mistakenly brought into their samples patients who have a primary psychiatric disorder and not ME/CFS. If these investigators thought there was no difference between psychiatric disorders and ME/CFS, they would not see this as a problem. However, these are distinct illnesses. If you asked a person who has Major Depressive Disorder what would they do tomorrow if they were well, they would probably not know. They would not know what it is they want to do. That’s part of the illness. In contrast, if a person who had ME/CFS was asked the same question, they’d probably start giving you a list of activities they’ve wanted to do but have been prevented from. You can see these are two classic different illnesses. Combining them together is a major conceptual methodological problem.

    Slide 11

    In this diagram, you can see that those with chronic fatigue (that means six or more months of fatigue) are only a small proportion of the people who have ME/CFS. There’s only a small proportion of this group here (circling ME/CFS) within a larger group (chronic fatigue circle) with chronic fatigue. Many people with major depression also have chronic fatigue (overlap between depression and chronic fatigue circle) this group right here. But if slippage due to the case definition allows investigators to bring into the ME/CFS category all those with depression and chronic fatigue, then these investigators will be studying mostly depression rather than ME/CFS.

    Slide 12

    In a study I conducted with Caroline King a number of years ago we selected two groups of patients: those with depressive disorder and those with ME/CFS. In that study, we were able to differentiate these two groups with 100% accuracy using the variables that are on this slide. And these were the variables: percent of time fatigue was reported; post-exertional malaise severity; unrefreshing sleep severity; confusion or disorientation severity; shortness of breath; and severity of self-reproach. You can see here (circling symptom list) we are talking about severity not just occurrence. That’s a very important issue we’ll talk about later. So we were able to differentiate these two groups. And the differentiating variable shortness of breath, for example, is not even found on the Fukuda criteria. Patients with depressive disorder have high levels of self-reproach, lots of negative things they say to themselves, but this is not found among patients with ME/CFS. This study suggests that these are two separate disorders, and it is critical for our case definition to distinguish these different illnesses.

    Slide 13

    Is it possible that this failure to differentiate Major Depressive Disorder from ME/CFS has led to variant prevalence rates of this illness? Let’s look at that on this slide. From 1997 to 2007, over a decade, the CDC presented prevalence data suggesting that rates of ME/CFS had gone from a relatively rare disorder affecting maybe 20,000 people to one affecting more than 4 million in the United States. So in 1997, we see 4 to 8 persons per 100,000 in a four-city study, and then in 2003 we see the rate go up to 240. In 2007, the rate going up to 2,540 cases of CFS per 100,000. This is an exponential, almost unprecedented, rise in a disorder. As you might imagine, I am skeptical about the CDC’s sizable increase in the numbers of estimated patients with ME/CFS in the U.S. over the past decade. The question is what might account for these escalating rates? And it is possible that changes in the case definition might play a large role.

    Slide 14

    I contend that changes from 1997, which is this little sliver right here (pointing to leftmost column), this is cases per 100,000 (pointing to y-axis) to 2003 (pointing to middle column) that this jump that occurred might be due to the way the CFS cases were identified. The larger jump from 2003 to 2007 (pointing to right column) might have been due to changes in the operationalization of the case definition. I might add that similar increases in prevalence rates have been reported by some investigators in Great Britain.

    Slide 15


    Now let’s try to figure out what these changing rates are about and see if we can come up with some possible explanations for that. In the late 1980’s and early 1990’s, the CDC engaged in a prevalence study that involved having medical personnel in four cities identify patients who have CFS, and then these individuals were medically examined. So individuals were referred by the physicians and then they were evaluated to see whether or not they had the illness. The findings released by the CDC in 1997 indicated that CFS was a relatively rare disorder affecting about 20,000 people. Yet if the physicians did not believe that CFS existed, they would not refer patients to the study. In addition, if patients didn’t have physicians because they were poor due to the illness, and had many of their resources having been used to try to get medical care, then they also would not have been referred. Therefore, these findings were likely underestimates of the true prevalence of CFS. And as we said earlier if an illness is perceived as relatively rare, less public and federal resources will be devoted to that illness.

    Slide 16

    Our group in Chicago used a different method to collect data by telephone and we would call a random sample of people in the Chicago area. Those who had the core symptoms were invited in for a complete medical and psychiatric evaluation. This is called community-based sampling, and using this method we estimated that about 800,000 people or more had ME/CFS which was - as you recognize - was considerably higher than the prior CDC estimates. In addition, we found that 90% of the patients had never been diagnosed with ME/CFS prior to our study. You can see this is the rate that of CDC and this is the rate that we got from our Chicago study. (pointing out graph on right of slide) I might add that in 2003, the CDC also reported on a community-based prevalence study and their findings were comparable with the DePaul sample. However, in 2007 in another report by the CDC, prevalence rates had soared. It is possible that changes in the case definition accounted for these increases. But first let’s go back to considering the essential elements for an illness case definition to see where the problem might be.
  8. Gerwyn

    Gerwyn Guest

    I was very interested in the proposal to classify ME and CFS as seperate illnesses.I notice that Susan and Kim studiously avoided any mention of neuroimmune endocine symptoms in their recent article on CFS.

    The CDC also appear to hold the view that ME and CFS are seperate illnesses

    Anyone with any thoughts?
  9. jspotila

    jspotila Senior Member

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    Since this is a transcript thread, may I suggest that questions not directly based on the transcript go in another thread?
  10. Gerwyn

    Gerwyn Guest

    I thought it was a thread about Jason's webinair.It seems sensible to raise issues regarding the presentation when people have all the information readily to hand. presentinga transcript without inviting comment seems redundant
  11. _Kim_

    _Kim_ Guest

    Thanks to the transcribers for this effort. I am usually on the transcribing team, but I have other obligations this week that take precedence.

    It's been customary for Cort to publish transcribed lectures as full articles and for the threads where the transcriptions appear to be sprinkled with comments.

    When all of Jason's lecture has been transcribed, let Cort know and he will pull them all together and post them as a new article.

    Carry on, Gerwyn.
  12. OverTheHills

    OverTheHills

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    Whoops!

    :eek::eek::eek:So Jennie it looks like you started at 17:10, where my first post finished!

    Fortunately I had not started doing 17:10 - 25:00 myself so we have not duplicated.

    This time I will start where you have stopped (when I work out where that is:D) and will edit this post to let you know where i will stop.

    Welcome to the world of cognitive impairment everyone:tear:
    OTH

    PS looks like you finished at 32:00 Jennie so I will pick up from there and go through to 42:00 in case anyone is thinking of more transcribing.
  13. creekfeet

    creekfeet Sockfeet

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    Thank you so much, transcribing team! This is wonderful stuff. Gerwyn, I can't see the slides so I'm uncertain, but it sounded to me like maybe he was differentiating not between ME and CFS, but between ME/CFS and other chronically fatiguing conditions.
  14. jspotila

    jspotila Senior Member

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    Thank you, Kim, for the clarification. This is the first time I've actually tried transcribing anything for PR. I'm sorry I didn't know the rules! Gerwyn, I apologize for trying to constrain the thread.
  15. CBS

    CBS Senior Member

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    Appropriate for this thread

    This doesn't have anything to do with this thread. Off topic and its' placement between an observation on Dr. Jason's presentation and unrelated view of what the poster believes is the CDC's position on ME and CFS (although lacking details of the types of different diseases either Dr. Jason or the CDC may hold) could easily be construed as an attempt to imply that Dr. Vernon and Ms. McCleary hold similar views.


    You asked for my thoughts. Given the thread's topic, I think this was an inappropriate/off topic cheap shot at the CAA. There.
  16. Martlet

    Martlet Senior Member

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    Moderator: I agree with CBS. Please would you stay on topic, Gerwyn? There are plenty of threads where criticism of the CAA is rampant.
  17. OverTheHills

    OverTheHills

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    Dr Jason part 3 - 32:00 - 42:00

    Slide Criterion Variance

    Criterion Variance is a complex term, but it’s a critical one. As I’ve been emphasizing, its important for two independent investigators to identify comparable patients for science to progress. But if your rules for identifying who is a patient and who is not a patient differ then problems will occur with the scientific enterprise. And that’s really what this criterion variance is about and that’s why its such a critical concept for scientists.

    Slide Requirements for Reliability

    So any good case definition has to be able to develop ways of defining symptoms so that different clinicians or researchers would agree as to whether a patient has a group of symptoms or not.

    Slide CFS Definitional Symptoms

    On this slide, the vertical axis refers to intensity of symptoms, where 0 would mean low intensity and 100 very high intensity. The horizontal axis refers to the Fukuda symptoms, the orange bar refers to how a person feels today and the yellow bar refers to how a person feels during their worst period of illness. As you can see this person has very low intensity symptoms, but still there are 4 symptoms. This person is actually a healthy individual. What this indicates is that the Fukuda symptoms are commonly reported by the general population.

    Slide CFS Definitional Symptoms(2)

    On this slide you see a completely different pattern. This is a patient with ME/CFS. As you can see, it’s the intensity, or the seriousness of the symptoms that differentiates the person with ME/CFS from a healthy person. In other words, you cannot just rely on the occurrence of a symptom but rather the intensity of a symptom to really differentiate those with and without ME/CFS. Let me give another example of this important point.

    Slide Percent reporting Fatigue for 6 months or longer

    Here we have three groups of patients: one group has ME/CFS, one group has MDD (Major Depressive Disorder), the third group is actually healthy controls. If you asked these three groups whether they have experienced six months of fatigue, you can see on the vertical axis that the ME/CFS group is really no different from the depression group. There’s no significant difference between these two groups, they are different from the healthy controls but these two groups are not significantly different. Both groups experience chronic fatigue if you ask them whether they experience the occurrence of it. Close to 90% or more of the individuals, the ME/CFS group almost 100%.

    Slide Percent reporting Fatigue for 6 months or longer (2)

    But if, with the same three groups, you examine the severity of fatigue over the past 6 months, not just the occurrence the severity of fatigue differentiates these particular groups. So from 0 severe to 100 severe the ME/CFS group is saying its about 80 – its pretty high, the MDD group is less than 50 on a hundred-point severity item. The control group of course much lower.
    So on severity you can differentiate these two conditions, not on occurrence, an important methodological point.

    Slide Additional Issues to be Considered

    Its also important to make sure that information is elicited from structured interview schedules, so that all questions are asked in the same way.

    Slide Responses Vary Depending on How the Question is Asked


    So lets take an example of that, what if you were trying to assess post-exertional malaise, and you asked the person

    “do you have prolonged (> 24 hour) generalized fatigue or malaise after previously tolerable levels of activity, and this is a problem since you got chronically fatigued”

    To that question we found that 59% of people with ME/CFS answer yes. But think about this question, its complex, there’s many parts to it. Some people may get lost trying to understand what is being asked. For example what is ‘previously tolerable levels of activity’, people might interpret that differently. So its critically important to have good questions that really assess, validly, the patients symptoms and its easy to get it wrong, that’s why its so important to have an interview schedule that lays out how to ask each question on these surveys.

    Slide New CDC CFS Empiric Definition

    Well in order to deal with a number of these problems, Reeves and his colleagues at the CDC in 2005 developed an ‘empiric definition’ which was supposed to identify people with CFS with more precision. Its beyond the scope of this webinar to discuss all the criteria of the CDC that they proposed, but lets examine one part of the criteria, that deals with identifying whether a person has sufficient disability to be included as a person with CFS.

    Slide Criteria for New Empiric CDC Case Definition Threshold for Disability


    In order to meet the threshold for disability, according to the Reeves Empiric Case Definition, they used an instrument called the Medical Outcomes Survey Short-Form 36. Let me again emphasize that this Reeves Case Definition was the one that was ultimately used with the Georgia prevalence study that indicated that over 4 million people have CFS. So on this Medical Outcomes Survey a person could reach the disability criterion for CFS by scoring lower than 25 percentile on one or more of the scales for: physical functioning , role physical, social functioning but in red [on the slide], I want to emphasize role emotional. So if you just met the criteria for role emotional, which means problems with work or daily activities as a result of emotional problems, you would then meet the disability criteria according to the Reeves Empiric Definition. The older Fukuda criteria never mentioned that emotional problems should be the reason for substantial reductions in functioning.


    Slide Implications of Role Emotional for Identifying Disability

    So here we have a major change, and this is the problem with these criteria. Using the lower 25th percentile for this role emotional scale every person who suffers from clinical depression would meet the disability criteria for CFS.

    Slide Evaluating the Empiric Definition

    Our group in Chicago recently used the Reeves Empiric Criteria with two groups of patients those with CFS and those with major depression. We found while all those with CFS were identified as having CFS, we found that 38% of those with major depressive disorder would also be classified with CFS (that’s what this green bar indicates). In other words Reeves and colleagues Empiric Case Definition was over-inclusive and possibly bought people into the diagnostic criteria that did not have ME/CFS. Let me give a case example of one of the people that we tested who we thought was mis-classified.

    Slide Case Study


    This person was a female with Major Depressive Disorder, this female met all the criteria based on Reeves’ Empirical Criteria, including role emotional functioning at the lowest 25% to meet the disability criteria. She demonstrated impairment with emotional and social functioning, two important traits of depression. But this person on a measure of physical functioning scored the highest possible score, indicating she had no difficulties with physical functioning. This would indicate that she did not have ME/CFS and yet had been mis-classified based on the Reeves and others Empiric Criteria.

    Slide Screening tests need high sensitivity and specificity

    Any screening or diagnostic has to be able to correctly identify those who have an illness, such as ME/CFS, and also correctly identify people who do not have an illness. This refers to the sensitivity and specificity of a test. In particular, when you have a low-prevalence illness such as ME/CFS unusual problems can occur, and these involve sensitivity – identifying those who really have the illness, and specificity – making sure you don’t identify those who don’t have the illness as having it. And the Bayes theorem is something that we’re going to talk a little bit about because it has some very interesting implications for this discussion.
  18. OverTheHills

    OverTheHills

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    Appeal for Technical help!!

    :Sign Help::Sign Help:

    As per my previous post, I really need some technical help with getting the slides into the body of the transcript. Without the slides the talk is pretty incomprehensible, and I don't think anyone wants to try and flick between the slide set and the transcript to understand.

    So far I have failed with printscreen from the windows media player recording, and failed cutting and pasting individual slides from the PDF file. This second method works fine for a word document but when I copy and paste it onto the thread the slides vanish.

    I am hoping for help as I want this work to be useful

    No transcribing for a couple of days as I have a doctors appointment (very low expectations)

    OTH
  19. Gerwyn

    Gerwyn Guest

    there is noway I was critisising the CAA i raiseda question on jasons presentation how is that off topic
  20. Gerwyn

    Gerwyn Guest

    How is a quote about the CDC a cheap shot at the CAA.Was my observation innacurate in any way.jason clearly stated thet the illnesses were to be classified as seperate.The CDC are on record as stating that the two illnesses are seperate .So I,m afraid your characterisation of my post is objectively innacurate.Surely thoughts about jason,s presentation are appropiate on a thread which purports to transcribe what he said?

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