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Tom Kindlon's submission to CFSAC (Oct 09 meeting) (draft)

Discussion in 'Action Alerts and Advocacy' started by Dolphin, Oct 12, 2009.

  1. Dolphin

    Dolphin Senior Member

    (Part 1 of 2)

    For what it is worth, here is my draft submission. The Word version I'm
    sending has underlining, italics, bold, different fonts, etc - if somebody
    wants a copy, PM me with your E-mail address and I'll E-mail it (the Word version) as it's easier to read. Don't have time/energy to make it fancy here.

    Any comments, typos, etc are welcomed - however this just fits on five pages so it's not easy for me to add more (although I could make the borders
    slightly smaller and shrink the font from size 12 Times New Roman if
    necessary). One person told me you can't use "sporty" like this in the US so will change that (she suggested athletic - but does that cover the fact that I wasn't just fit but actually played lots of sports?)

    If anyone wants to make similar points, feel free!! (It might re-inforce the
    I figure loads of people will be making comments about XMRV so didn't say
    anything on that (no space).

    Tom Kindlon
    ==========================================================Don't support the Reeves/empirical definition/criteria for CFS?
    Sign the petition at:

    Tom Kindlon's Written Testimony: CFSAC Meeting October 2009

    My name is Tom Kindlon. I have CFS (or ME or ME/CFS, the terms I prefer)
    for over 20 years, having previously been healthy (and very "sporty").
    Unfortunately it took me over 5 years to get diagnosed. By the time I was
    diagnosed I was virtually bedbound and I have only improved a small bit
    since then i.e. I have been housebound with CFS for over 15 years.

    I have been on the committee of the Irish ME/CFS Association (formerly the
    Irish ME/CFS Support Group) since 1996 and have been Assistant Chairperson
    since 1997. I have been active in the ME community internationally in
    various ways.

    I believe I have a lot of useful knowledge and experience in the area. In
    the last twelve months, I have had letters on the subject of CFS published
    in four peer-reviewed journals (British Medical Journal, Brain (a neurology
    journal), Bulletin of the IACFS/ME and Pain Medicine) and have two more "in
    press" (Psychological Medicine and Journal of Rehabilitation Medicine (this
    one was co-written with Ellen Goudsmit PhD)).

    I want to make three points:

    1) I am very concerned about the "empirical" definition (Reeves, 2005) the
    CDC has adopted for CFS research in recent years

    I set up a petition on the issue on the 15th of April, 2009. This petition
    is summarized in 10 words as,
    "CDC CFS Research should not involved the empirical definition (2005)"

    The petition

    We call on the Centers for Disease Control and Prevention (CDC) to stop
    using the "empirical" definition[1] (also known as the Reeves 2005
    definition) to define Chronic Fatigue Syndrome (CFS) patients in CFS

    The CDC claim it is simply a way of operationalizing the Fukuda (1994)
    definition[2]. However the prevalence rates suggest otherwise: the
    "empirical" definition gives a prevalence rate of 2.54% of the adult
    population[3] compared to 0.235% (95% confidence interval, 0.142%-0.327%) and 0.422% (95% confidence interval, 0.29%-0.56%) when the Fukuda definition was used in previous population studies in the US[4,5].

    The definition lacks specificity. For example, one research study[6] found
    that 38% of those with a diagnosis of a Major Depressive Disorder were
    misclassified as having CFS using the empirical/Reeves definition.


    [1] Reeves WC, Wagner D, Nisenbaum R, Jones JF, Gurbaxani B, Solomon L,
    Papanicolaou DA, Unger ER, Vernon SD, Heim C. Chronic fatigue syndrome--a
    clinically empirical approach to its definition and study. BMC Med. 2005 Dec
    15;3:19. Link:
    [2] Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The
    chronic fatigue syndrome; a comprehensive approach to its definition and
    study. Ann Int Med 1994, 121:953-959.
    [3] Reeves WC, Jones JF, Maloney E, Heim C, Hoaglin DC, Boneva RS, Morrissey
    M, Devlin R. Prevalence of chronic fatigue syndrome in metropolitan, urban,
    and rural Georgia. Popul Health Metr. 2007 Jun 8;5:5.
    [4] Reyes M, Nisenbaum R, Hoaglin DC, Unger ER, Emmons C, Randall B, Stewart
    JA, Abbey S, Jones JF, Gantz N, Minden S, Reeves WC: Prevalence and
    incidence of chronic fatigue syndrome in Wichita, Kansas. Arch Int Med 2003,
    [5] Jason LA, Richman JA, Rademaker AW, Jordan KM, Plioplys AV, Taylor RR,
    McCready W, Huang CF, Plioplys S. A community-based study of chronic fatigue
    syndrome. Arch Intern Med. 1999 Oct 11;159(18):2129-37.
    [6] Jason, LA, Najar N, Porter N, Reh C. Evaluating the Centers for Disease
    Control's empirical chronic fatigue syndrome case definition. Journal of
    Disability Policy Studies 2008, doi:10.1177/1044207308325995.

    Further reading: Leonard Jason, Ph.D., DePaul University. Problems with the
    New CDC CFS Prevalence Estimates i.e.

    I'm the first to admit that this isn't exactly the "catchiest" petition that
    has ever been created. One might think it would be lucky to get a few dozen

    However already 1633 people have signed (at the time
    of writing). Many have left comments which can be read on the site:
    [Aside: other people have also left comments but for some reasons the
    comments have not gone up].

    I believe this shows the depth of feeling there is on this issue.

    As I said in my last submission, if one looks at the CFSAC function, it is
    clear that the issues relating to the definition are fairly central.

    I listed numerous problems regarding the definition in my submission to the
    May 2009 CFSAC meeting
    ( so
    I'm not going to repeat them now.

    I do not believe that Dr Bill Reeves adequately dealt with the concerns
    about the Reeves 2005 criteria in the last meeting. He said that the
    difference between the prevalence rates they found in Georgia (2540 per
    100,000) compared to previous estimates (235 and 422 per 100,000) were down to two issues:

    - the different methodology in the Georgia where they brought in people who
    did not complain of fatigue on the telephone screening. He said that "20-30
    percent of people who did not complain about fatigue endorsed the Fukuda
    criteria." However, the paper for which he is the corresponding author
    actually gives a lower figure of 11.5% ["In other words, 11.5% of subjects
    with CFS would not have been detected in previous studies that queried
    participants only for fatigue"]. It should also be remembered that some of
    these people might not have satisfied the criteria for Fukuda as it is
    normally applied - the Reeves criteria make it easier to satisfy the
    criteria. So the real figure could well be less than 11.5%. But even if
    one takes the figure of 11.5%, that would only bring the figures of 235 and
    422 per 100,000 up to 266 and 479 per 100,000 which are still dwarfed by the
    2540 per 100,000 prevalence rate from the Reeves criteria (2005).

    - The other point he starts talking about in this section is criteria
    regarding major depressive disorder so he may have been trying to make a
    point with regard to this. Personally I agree with him and see this as an
    important area also! First a quick aside: there are various forms of
    depression e.g. dysthymia, atypical depression, etc. In the past, apart
    from bipolar, the main one excluded was MDDm (melancholic Major Depressive
    Disorder), a severe type of depression. Many people still had depression
    but were included as they satisfied the criteria.

    With the Reeves (2005) criteria, it says: "Following recommendations of the
    International CFS Study Group, only current MDDm was considered exclusionary for CFS." However, part of the specific recommendations of the International CFS Study Group [1] that (Reeves claims his definition is based on) was that MDDm had to have been resolved for more than 5 years:
    "The 1994 case definition stated that any past or current diagnosis of major
    depressive disorder with psychotic or melancholic features, anorexia
    nervosa, or bulimia permanently excluded a subject from the classification
    of CFS ... we now recommend that if these conditions have been resolved for
    more than 5 years before the onset of the current chronically fatiguing
    illness, they should not be considered exclusionary."

    It might not be important to point this out for definitions for some
    illnesses: however if one looks at table 2 of the 2005 paper, 6 of the 16
    who are said to have CFS using the "current classification" of CFS, had been
    diagnosed with MDDm at a previous assessment which suggests it is important
    in this context.

    Also Leonard Jason published a study which found that 38% of those who have Major Depressive Disorder but not CFS would satisfy the symptom, fatigue, etc criteria in the Reeves definition.

    Also the Nater et al. (2009) study found that 57% had current psychiatric
    disorders and 89% had lifetime psychiatric disorders, suggesting the
    definition is picking up a group with a lot of psychopathology.

    [Aside: A lot of people have made suggestions to me speculating why the CDC
    broadened the criteria in the way I have. I do not know the answer. The
    most plausible theory to me is the following: The CDC followed patients in
    the community in 1997, 1998, 1999 and 2000. Between December 2002 and July 2003, they were brought in for intensive testing. In total, 227 people were invited in, including 70 who had previously been diagnosed with CFS. These people went through very expensive testing - the whole exercise cost $2m. However, unfortunately, only 6 out of the 70 cases of CFS satisfied the
    Fukuda definition when they were brought in. Also 4 more of the other
    individuals also satisfied the definition. If one only excludes people who
    currently have Melancholic Major Depressive Disorder (MDDm) (which was not
    the recommendation of the International CFS Study group), one can get the
    numbers who satisfy the Fukuda definition up to 16. The CDC admit this in
    their paper (Reeves, 2005). However 10 (or 16 if one allows all the MDDm
    cases) people with CFS would not be enough for the CDC to publish CFS
    studies with a lot of the data they have. For some of the experiments,
    people would not have been suitable for one reason or another e.g. they were
    on medication. Also, often data is not complete or tests become corrupted
    so a percentage is lost. For some of the experiments, gender might make a
    difference and one may end up excluding the men as there might not be enough patients. So 10 or 16 CFS patients is not enough to publish CFS papers using this data. But $2m of the CFS fund had been spent on this experiment and it might look like a waste of taxpayers' money if papers were not published. The CDC had already gotten into trouble for misusing the CFS
    budget in the past. So the definition of CFS was expanded so that CFS
    papers could be published. So that's one plausible theory although one does
    not need to accept that to believe that the empirical definition is flawed].

    Even if for some reason, the CFSAC do not want to recommend against the
    definition, it would be good if you pressed the CDC to make clear in each
    and every paper they write that they use the empirical criteria, that they
    were used. The reference for the empirical criteria is often not being put
    in the list of references. I know the patients were selected using the
    empirical criteria because they are part of the 2-day Wichita study cohort
    or from the Georgia study but most people reading the papers will not know


    2) I think the CDC CFS program should have to cut its ties with Peter White,
    according to its own rules regarding external reviewers:

    At the May 2008 CFSAC meeting, the following information was given on the
    CDC External Peer Review of CFS Program

    "CDC plans to conduct an external peer-review of the CFS program in late
    summer/early fall 2008. This review will be conducted by a panel composed of
    national and international experts that is to include representatives from
    the Coordinating Center for Infectious Diseases Board of Scientific
    Counselors and CFSAC. CDC is requesting that CFSAC members recommend names of experts with no conflict of interest (direct funding from CDC)"


    Dr. Miller:
    "The panel will be external experts in the field who have no conflict of
    interest-they are not receiving CDC funding and ***would not have a direct
    impact on the program in its development in stages other than the

    One of the external review panel (which was small - only 4 people wrote the
    report), was Dr Peter White. At the May 2008 CFSAC meeting, Dr Bill Reeves
    said: "We talk to Dr. White fairly regularly."

    It is unclear who nominated Dr. White to the panel of external reviewers -
    perhaps the CFSAC could ask this. It was not the CFSAC as the minutes show. Dr. Reeves talked as if they might have been suggested Dr. White be involved because he was an "expert on autonomic nervous system function." (which is a curious statement to make given Dr White is a psychiatrist, whose
    PubMed-listed articles do not suggest he is an expert in this field).

    Anyway, the external review panel made the following recommendations:
    "The panelists recommend that the CDC program urgently consider intervention studies to help to elucidate the direction of causality in the several pathophysiologies identified by the CDC. This strategy was not articulated clearly. For example, since both cognitive behavior therapy and graded exercise therapies are known to address some of the abnormalities found, and since both these therapies have been shown to be efficacious for CFS, these behavioral interventions should be seriously considered. Collaborations with providers and medical schools practised in randomised controlled trials might provide the best means to achieve this."

    A summary of strategic recommendations
    5. Clinical guidelines on management should be developed for use in the USA,
    by the CDC team in collaboration with others, and disseminated for CFS.

    6. The team needs to consider studies that test the direction of causality
    of pathophysiology, such as using interventions."

    At the May 2009 meeting, Dr Reeves said:

    ""Peter White, the psychiatrist that we work with at Emory,"

    "We are in the process of planning a cognitive behavioral therapy (CBT) and
    graded exercise (GET) trial as part of the provider registry population in
    Macon. We're going to do that in collaboration with the providers in Macon,
    with Mercer Medical School, ***with the U.K. group***, and with Mayo

    - "International Workshop - Research, Clinical, and Pediatric Definitions of
    CFS - I would like to try to get together by the winter of 2009. I know the
    IACFS/ME is interested in this. We want to include countries such as UK that
    have CFS care completely integrated into their healthcare system."

    - "Dr. Reeves: An excellent comment. Our focus is obviously on the United
    States. There are three important reasons for international collaboration.
    One of them I alluded to. There are countries that have put CFS evaluation,
    diagnosis, and management into their national health systems. The UK is one
    of those. An international meeting provides the chance to learn from another
    government that has embraced this illness- perhaps not to the extent that
    everybody would like-but is trying to work with it as a national health

    Given that the only representative from the UK that the CDC has invited to
    its CFS meetings since around 2001/2002 is Peter White, it looks very likely
    that they have him in mind for both of these workshops. Also it looks like
    he is involved in their Emory research and may be involved in the CBT/GET.
    Both for the CDC's reputation and Dr White's, it would be better if the CDC
    cuts its ties with him given he took part in the external peer-review.
  2. Dolphin

    Dolphin Senior Member

    (Part 2 of 2)

    3) There is potential that who the individuals the CDC invites to its
    upcoming workshops may not be representative of the spectrum of opinion
    amongst experts in the field, based on the make up of, for example, some
    International CFS Study Groups previously

    The CDC are planning to have three workshops on CFS (according to their
    draft plans):

    - International Workshop - Clinical Management of CFS

    - International Workshop - CFS Case Definition

    - Workshop International - CFS Study Group (Research priorities)

    However, it should be remembered that, for example, what is considered good
    management of CFS is a highly disputed area. Many professionals believe
    that Graded Exercise Therapy (GET) and Cognitive Behavioural Therapy (CBT)
    based on GET are basically all that patients need. Symptoms are seen as
    largely due to deconditioning and maladaptive beliefs and behaviours rather
    than an ongoing disease process. I will call these the people of the "CBT
    School of Thought."

    A few professionals go further and claim that GET and CBT based on GET can
    lead to full recovery. This is a small group but it includes Peter White
    (mentioned above) and the psychologist, Gijs Bleijenberg PhD from the
    Netherlands. Both of these professionals, who many would consider to have
    extreme views, have been the sole representatives from their countries at
    workshops the CDC have organised on the illness (see for example ).

    The CDC was involved in a paper this year, "Are chronic fatigue and chronic
    fatigue syndrome valid clinical entities across countries and healthcare
    settings?" by Hickie I, Davenport T, Vernon SD, Nisenbaum R, Reeves WC,
    Hadzi-Pavlovic D, Lloyd A and International Chronic Fatigue Syndrome Study
    Group (28 collaborators). Of the 35 individuals involved, apart from the
    CDC team members, virtually all could be said to be of the CBT School of
    Thought with regard to CFS.

    However, a meta-analysis (Malouff et al., 2008) found that the average
    Cohen's d effect size for Cognitive Behavioural Interventions (include GET)
    for CFS was 0.48 which does not reach the threshold of 0.5 for something to
    have a moderate effect! Leonard Jason published a large NIH-funded study in
    2007 which found that an intervention based around encouraging patients to
    pace activities did better than interventions that assessed CBT or exercise
    programmes. Prof. Jason subsequently published a paper which found that
    within this trial, "Those who were able to stay within their energy envelope
    had significant improvements in physical functioning and fatigue severity."

    Is the CDC going to ensure that there are a reasonable numbers of
    individuals at these workshops who believe that pacing is a good management
    strategy for CFS? Some/many in the CBT School of Thought are against pacing and will not recommend it. Are the CDC going to ensure there will be
    proponents of Energy Envelope Theory at these workshops? Also I don't think
    one person is sufficient given group dynamics.

    An even more important issue is the high rate of adverse reactions reported
    by people with CFS who have done exercise programmes (and CBT based on
    exercise programmes). Unlike drugs, generally there is no easy way for
    professionals or individual patients with CFS to report adverse reactions to
    non-pharmacological interventions such as GET. So formal data is not
    systematically collected by statutory agencies in countries around the
    world. Surveys on the issue are the next best source of information it
    would seem. I sent information on 10 such surveys to the CDC in my
    submission on their draft plans - see i.e. Kindlon's Submission
    %20on%20CDC%20Draft%205-year%20Strategic%20Plan%20for%20CFS%20-%20June%202009.pdf .

    These are surveys from various countries (the UK, US, the Netherlands and
    Norway) and show the high rates of adverse reactions that are reported. The
    latest survey was from the UK, by the ME Association: 906 replies: Made much worse: 33.1% (300 individuals), Slightly worse: 23.4%, No change: 21.4%. Improved: 18.7% and Greatly improved: 3.4%. These represent very high rates of adverse reactions. If a drug made 33.1% "much worse", it would probably be taken off the market until they worked out if there were certain groups of patients for whom it was, and was not, appropriate. Dosages might be changed.

    Some proponents of GET for CFS claim that it is simply because the GET was
    not done under a suitable professional. However, in the UK, where CFS
    clinics have been set up around the country, this was investigated in a
    survey by AYME/AfME (May 2008). They asked about experiences of GET in the three previous years. This was after the specialist services had been set
    up. There was no statistical difference between the rate of adverse
    reactions in those who did GET under an "NHS specialist" and the people who
    did GET under other individuals or by themselves.

    Even if it was the case that GET is only unsafe when not done under an
    appropriate professional, GET is available "over the counter" so if guidelines from the CDC and others recommend it, many patients will try this treatment.

    Many proponents of GET and CBT based on GET do not impart information on the high rates of adverse reactions to either the patients themselves or even
    other professionals when they are educating them about the interventions.
    Some use the "catch phrase" that they are "safe and effective." The CFSAC
    should insist that any guidelines should give information on adverse
    reactions either with specific information or simply generally points about
    the high rates of adverse reactions that have been reported.

    Perhaps the CFSAC (and indeed other groups) could have a role in
    recommending names for these workshops to ensure these workshops are
    balanced e.g. the CFSAC get to recommend 25% of the groups, the IACFS/ME
    another 25%, a patient group such as the CAA 10% and the CDC 40%. (Groups could give alternates if some of their picks were already used).

    Suggestions for professionals from the UK who I would think would give
    balance to any workshops are: (i) Charles Shepherd MD ; (ii) Ellen Goudsmit
    C.Psychol. PhD FBPsS (Health Psychologist and Visiting Research Fellow,
    University of East London) ; (iii) Abhijit Chaudhuri DM MD PhD FACP FRCP (a
    consultant neurologist) ; (iv) Neil Abbot MSc PhD (Operations Director, ME
    Research UK) and (v) William Weir MD (an infectious disease consultant who
    ran an NHS clinic for ME for a number of years)
  3. MEKoan

    MEKoan Senior Member

    What an achievement! I don't know how you managed to write this because I can't even read it. I'm going to message you my email for a word copy.

    In NA sporty has more to do with style - a sporty shirt, for instance. It might conjur up a picture of someone who was dapper in a casual way.

    Athletic does imply that one plays sports or cycles, etc. One could also say one was involved in organized sports or specify the sport(s).

    What an achievement! Can't say that too much!
  4. Dolphin

    Dolphin Senior Member

    Ok, thanks for that - will change it. I wonder did "Sporty Spice" (from the Spice Girls) confuse people!

    I can listen to comments like that all day - thanks. :) Although if you're saying it after you read it, I'll be even more pleased.
  5. leelaplay

    leelaplay member

    wow Tom, impressive. I'm like Koan in that I can't read it all, but from what I can digest, you really know your (our) stuff. And I LOVE the petition. Not sure how to do this - do I write to Cort to see if it can be set up as a separate thread? - think you'd get lots of signatures if it was more visible.

    Tiny typos I saw were:
    pg 1 line 1 - I have had Me/CFS for ....
    Aside: A lot of pple... in the way they did (I think instead of I have)
  6. kolowesi

    kolowesi Senior Member

    Central Texas
    TomK written submission

    Thank you so much, Tom.

    You hit on the most important points from my point of view, and boy oh boy, did you back them up.

    I am wondering what to write. In May (?) I sent my personal history of GET and CBT or rather CBT-not, as my therapist believed I was physically ill.

    I could add onto that as I have now tried physical therapy with specifically non-aerobic exercise, and managed to go for 5 weeks (with a couple of skips) before a crash from which I have not recovered.

    I feel I should send something, but what you have done is far and away more useful than anything I can come up with. I could try to re-iterate your points at least.

    Thanks for your awesome work for us!
  7. Dolphin

    Dolphin Senior Member

    (Way off-topic)

    Ok, will take your word for that. The second version certainly doesn't seem incorrect.

    Any idea what the name of that tense would be? I can recall six from Latin (present (I am going/I go (I know there is a distinction but don't know it), past (I went), past perfect (I had gone), past continuous (correct name?) (I was going) (think it was called imperfect), Future (I will go), and Conditional (I would go).

    But I know in the Ancient Greek class there was supposedly lots more tenses.

    In Ireland, we didn't do much English grammar past the age of 10 or 11 so I think I may have some gaps (got 99 percentile in SAT verbal but not in Test of Standard Written English (TSWE - don't know if people in the US have to do that?)). I know lots of grammar for other languages (Irish/Gaelic, French, German and Latin) but don't tend to think about grammar for English.

    I just did the SATs as an aside one Saturday - our school didn't prepare us for them.

    Yes, that wasn't correct at all.
  8. Dolphin

    Dolphin Senior Member

    Thanks islandfinn.

    Finch kindly set up a thread on it at:

    Of course, there may be other ways to highlight it.
  9. Dolphin

    Dolphin Senior Member

    Thanks Kelly.

    Sounds like what you have in mind is good - I'll be happy if people make the same points as me, but then I might be biased!

    But saying you relapsed from exercise is important.

    If you want to make the analogy of a drug, it would be good. It's too easy for everyone to tell us we should exercise more - but with other treatments e.g. drugs, surgery, etc, professionals have to be much more careful about what they recommend. And tell you in advance possible side effects even if they are very rare. And then if various people have the same adverse reaction, this is noted. But with exercise for CFS, there aren't the same safety precautions in place.

    Medical bodies/agencies love the idea that all they need to do is tell people with CFS to exercise - it's much cheaper than having to pay for drugs for one thing.

    It's such a seductive idea that we could just exercise ourselves better. It causes problems all around the world. The CDC want to copy the UK where that's all that patients are offered (and doctors are told also not to prescribe other things as part of the guidelines). Anyway don't want to wear people out - if people send it something, it'd be good.
  10. leelaplay

    leelaplay member

    even more off topic - grammar +

    Ah - so innate intelligence, is it? I'm in Canada - I never had to those tests.
    And when I was at school we never studied grammar

    Present and present continuous I live here / I am reading
    past and past continuous I lived there / I was living there when xmrv was discovered
    (future the same)

    It's the present perfect (always liked the name) - a tense with a couple meanings, but the focus is comparing in some way past and present
    a) some unknown time before now
    eg I've been to Tibet.
    b) from the past to now for a period of time
    eg I've lived here for 20 tears
    Can you tell I was a language teacher? Think there are more for the present perfect, but am surprised I remember that much today

    I studied greek and latin + spoke passable french and spanish. Quite fluent, but grammar stunk - had a hard time with the tenses - embarrassing for a language teacher
  11. Dolphin

    Dolphin Senior Member

    (Still off-topic)
    Well, I happened to catch a snippet of Boston Legal yesterday where the lawyer with Asperger's is talking about SATs and with training people can boost their scores by 150 points.

    But there are certainly plenty of people out there who would be much better than me at learning languages. And more able in English. The SAT verbal was about the only top score I ever got in English.

    We didn't either in Ireland. The thought went through my had I might go to the US. But I had mild ME then (undiagnosed) and teh whole thought of the effort involved put me off.

    Thanks for that. That reminds me of French. I could never remember depuis/pendant/pour. I've noticed some people who don't have English as their first language mess that up in English.
  12. Dolphin

    Dolphin Senior Member

    (off topic: grammar)
    I was thinking about it.
    I wouldn't say "I have a car for 20 years" - I'd say "I have had a car for 20 years" so the "I have had CFS for 20 years" makes sense.
  13. Dolphin

    Dolphin Senior Member


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