Blood Products Advisory Committee Meeting Announcement (BPAC) December 14-15, 2010

[floydguy]

Even though OI is one of our worst symptoms, I doubt very many of us would consider the absence of that one symptom, "recovered". Regardless, apparently a significant group of people from that Bell cohort have reached a level of health they consider "recovered"......I would sure love it if we could get them on PR for a Q&A thread....any ideas?

I believe it's been discussed before that Bell's patients are not really recovered. The "recovered" people have been able to figure out how to be somewhat functional but are in no way recovered.

 

[Marco]

Hi Marco,
I feel really dissapointed about the conclusions as well...
But, in case you didn't notice, the committee did actually recommend that the FDA excludes CFS patients from donating blood (Although it didn't seem it was heading that way from reading the text). So this is a result.

I think this news kind of got buried a bit by the lack of clarity with the BWG Phase II results.

Didn't miss it Bob. But if the participants were confused as to just what they were voting on, as has been suggested, the FDA are under no obligation to accept the recommendation.

I hope not and am happy to accept the result regardless.

 

[Marco]

Marco,

They did have an agenda they followed that included discussion times. It just seemed to me that the BPAC members, other than Coffin and occasionally Klimas, didn't have much to say. I think Dr. Nelson, who asked the most questions, is also new, which may be why he asked so many and the other BPAC members, who probably went through the basic questions at the last meeting, didn't. Coffin questioned/spoke the most, other than Dr. Nelson during the Q&A/discussion periods after each presentation.

There was, indeed, a Chair, but he didn't demonstrate much skill at running at meeting. When the confusion ensued regarding what a Yes or No vote meant, he didn't appear to ensure that everyone was clear about what their votes would mean beforehand (as you saw in my notes, I wasn't either). However, after the voting, the Chair reiterated and re-read the question and stated that the recommendation of the Committee was to indefinitely defer. So, I have to think that if any of the members were surprised at the outcome, they would (certainly should) have spoken up at that point, and none of them did. The little patient group of us (the PA, his son, Heidi) were sure scratching our heads!

They didn't add a recommendation to provide educational materials to potential donors or give input on what a question about ME/CFS status might say, although this was discussed. Perhaps the scope of their recommendations is limited by the questions that were put forward in advance and they aren't permitted to broaden the scope? I don't know.

I'm also curious about what led to the additions of Coffin, Klimas (and apparently Nelson) to the Committee. If this was discussed at the last meeting and/or there's a thread somewhere about it, I'd really appreciate a link to it. Thanks.

Thanks Val.

Scrub my last post. Too impatient to answer and too afraid that I'd forget what I wanted to say while catching up with the rest of the thread.

 

[eric_s]

Thanks a lot Val, it was interesting to get more details about the BWG phase II results.

 

[Valb626]

Oh, another thing I wanted to mention was that, by the time they got to the discussion of the other 3 questions on the agenda, which didn't require a vote, the meeting had already gone over by about 1.5 hours. So, those questions didn't get much attention/discussion, as everyone was more than ready to leave by then.

 

[Cort]

Val has posted the slides on ME/CFS Forums and gave us permission to repost - so no sneaking around this time .

This gives us the why and what of the studies

Phase II - Pilot Studies

Purpose is to facilitate labs with divergent results to test clinically validated samples.

Two questions:
Whole Blood (WB) vs PBMC vs plasma (which to use for testing?)
-Original Lombardi study was performed on isolated PBMC and plasma
-Large scale studies for prevalence are facilitated by using WB or plasma
-Donor-recipient and other repositories are mainly comprised of frozen WB and/or plasma

Timing of Processing
-Processing and freezing of samples for (this) study varied from 2-4 days due to requirements for completion of infectious disease testing. Other frozen WB and plasma repositories were prepared 1-3 days post-phlebotomy.

-Studies with other cell-associated viruses (HERVs, HTLV, herpesviruses and annelloviruses) demonstrate that levels of viral nucleic acid in plasma and WB vary with time from collection to processing and frozen storage

 

[Cort]

Here are the 4 samples - all positives as identified by the WPI - an important point...

XMRV-positive samples

-WPI collected blood from 4 subjects (mostly with CFS) previously identified as XMRV positive in the Lombardi study (by PCR, serology and/or culture)

-Specimens separated into tubes and processed immediately, or left at 4 degrees C for 2 or 4 days

-Each specimen was processed into replicate PBMC, WB and plasma samples that were frozen for panel preparation

Analysis

-Unblinded panels were distributed to WPI and CDC and a blinded panel to NCI for testing (me - I don't remember any rationale given for this)

 

[George]

Oh, another thing I wanted to mention was that, by the time they got to the discussion of the other 3 questions on the agenda, which didn't require a vote, the meeting had already gone over by about 1.5 hours. So, those questions didn't get much attention/discussion, as everyone was more than ready to leave by then.

Val this includes the question about banning the Prostate Cancer Patients?? Do you think it was remanded to the next day or just skipped through??? I haven't found anything regarding PC patients being defered or banned in any of the news papers and I googled for that. Did I miss it??? Anybody else find the info on that one way or another??

I read through the slides you posted and Thank You again from the bottom of my little doggy heart.

Is it just me or are we completely lacking anything like a structure and the results are a mish mash. I was under the impression according to the presentation at CFSAC that the point was to create a "gold standard" test and the labs would test both their test and the "gold standard" and see who was better (?) or at least the most accurate.

That all seems to have gone completely out the window.

What are some other people's takes on this information??

And I am completley floored on the number of samples used. I'm thinking that either who ever designed this was drinking heavily or maybe I need to take up drinking heavily so that I can understand the idea process involved here! (and I am so not grining right now!)

 

[Cort]

Oh, another thing I wanted to mention was that, by the time they got to the discussion of the other 3 questions on the agenda, which didn't require a vote, the meeting had already gone over by about 1.5 hours. So, those questions didn't get much attention/discussion, as everyone was more than ready to leave by then.

Thanks for the on site review. I'm not sure what they were thinking was going to happen there...they squeezed, as conferences often do, the peakers into their little slots - I don't think they left much time for discussion. It would have been great to have taken questions from the audience as well......We always want more...

You know what I would really like? A debate - questions posed before hand and after - between say, Dr. Stoye and Dr. Ruscetti. They'd probably tell each other "I'll meet you outside in the parking lot afterwards"

But still that would just lay everything out in the open.....Don't they do that in retrovirology??? That's not part of the agenda???

 

[Cort]

You can see why they picked these patients: they had mostly consistently tested positive using a variety of methods..

Subject Characteristics

-4 females
-26-53 years of age
-3 were diagnosed w/ CFS over 20 years ago, one is a family member of a long-time CFS patient

(me-the info about test results may be from the original Lombardi study, but I'm not sure and I don't know what the X/X proportions refer to)

Information about Subject 1:

XMRV PCR positive 5/5 (nested)
XMRV seropositive 5/5
XMRV culture positive 3/5

Not a CFS patient, but a family member, not on ARVs

Subject 2 (leaving out "XMRV" in test results now):

PCR positive 1/1 (single)
Seropositive 1/1
Culture 4/4

CFS patient, no ARVs

Subject 3

PCR 0/1 (single)
Seropositive 1/4
Culture 4/4

CFS patient, no ARVS

Subject 4

PCR 10/10 (nested)
Seropositive 3/10
Culture 9/10

 

[Cort]

This is just interesting.... remember it was the CDC that was unable to find any XM RV in the samples the WPI sent to them just prior to publishing their study. This time some of the samples tested positive for the gag protein on two separate days..and most of them tested positive on another test. Yet they all tested negative using the DNA/RNA test.

The CDC was really close on two tests to the WPI! (that calls for a smiley I rarely use) :Sign Good Job::Sign Good Job: I know everyone dislikes the CDC - but it looks like they are playing straight science here and really everyone has an incentive to do so because no one nows what the other labs are going to find; which is a nice incentive to try and get this right. You can see from this why Switzer would say he really doesn't know what's going on.

Phase IIa - CDC Results (This is a very detailed table, so I have to summarize it)

No positives found for any subject using a WB DNA/RNA test on any days.

No positives found for any subject using PBL DNA/RNA test on any days.

Positive (?- there's either a symbol or letter before this, but can't read it)XGAG PCR results for Subjects 3 and 4 on Days 2 and 4. Sequenced XMRV.

Positive (looks like) off-PCR (pro) results for:
Subject 1 on Day 2, sequenced XMRV/MuLV (no results from Day 4, no explanation)
Subjects 2, 3 and 4 on Days 2 and 4, sequenced XMRV/MuLV


Notes:
-Plasma was ultracentrifuge pelleted prior to nucleic acid extraction
-All PCR positive samples tested negative for mouse mitochondrial DNA

 

[Cort]

Now here's the WPI

Thankfully their results were mostly consistent but not always. They were mostly consistent on days 2 and 4. They couldn't find anything on day zero. This is one reason why the WPI does multiple tests - it doesn't always show up.

Phase IIa WPI Plasma Results

Used nested RT-PCR for XMRV gag for all subjects.

Day 0 results negative for all 4 subjects.

Day 2 results positive for all 4 subjects.

Day 4 results positive for Subjects 2-4. Subject 1 was not tested (don't know why.)

Notes:
-Plasma processed using Qiagen Viral RNA kit
-WB samples were all negative for DNA
-PBMC were not tested

(There is also a figure on this slide that looks like PCR bands, but I can't read either the figure title or any descriptive info)

 

[Cort]

Now here's the WPI

Thankfully their results were mostly consistent but not always. They were mostly consistent on days 2 and 4. They couldn't find anything on day zero. This is one reason why the WPI does multiple tests - it doesn't always show up.

On the other hand they appear to have been unblinded - that suggests they sent them samples the WPI stated were positive and said now see if they are positive again......which seems crazy... why not throw a bunch of other samples in there and asked them to test them???

The WPI, on the other hand, seems to have done an honest job of it....

Phase IIa WPI Plasma Results

Used nested RT-PCR for XMRV gag for all subjects.

Day 0 results negative for all 4 subjects.

Day 2 results positive for all 4 subjects.

Day 4 results positive for Subjects 2-4. Subject 1 was not tested (don't know why.)

Notes:
-Plasma processed using Qiagen Viral RNA kit
-WB samples were all negative for DNA
-PBMC were not tested

(There is also a figure on this slide that looks like PCR bands, but I can't read either the figure title or any descriptive info)

 

[Cort]

National Cancer Institute :mask::mask::mask::mask:

Couldn't find it at all! Remember they are all just looking for the XMRV gag sequence via PCR....

We have the very odd scenario of the CDC been able to find XMRV and the NCI not being able to find it . So the group that was able to find it now can't, and the group that wasn't able to find it now can. Love it!!!

Just another day at work...

Phase IIa NCI/DRP Results

Single-copy quantitative PCR assay for XMRV gag

-Plasma spiked with internal control virus and ultracentrifuged prior to nucleic acid extraction using guanidinium isothyiocyanate and PCR was performed +/- RT step

-WB and PBMC extracted for DNA


All samples (plasma, WB and PBMC) and all days were negative

-Plasma internal controls for pelleting of virus and RT step were all in range
-WB and PBMC genomic DNA controls in range

 

[Cort]

Conclusions - as Val notes, the only lab that couldn't find is unblinded - so now they have to worry about the blinding factor - and we have to wonder why they didn't stick a few more samples in there - so they wouldn't have to worry about the blinding factor?? Arrgghhhhhhhhhhh! :Retro mad::Retro mad:this is why

I really want to know about that.....The way the results turned out could be interpreted as - blinding made a difference. Isn't blinding the first thing they do at this level? Critics took the WPI to task for not stating that they blinded their samples...and here the guys that are supposed to clear up the mess are not blinding their samples???

I wonder what the explanation for this is???

2/3 labs detected XMRV in clinical samples

- Plasma out-performed WB in both labs, and PBMC in the one lab that tested PBMC

-Day 2 and 4 samples out-performed Day 0 plasma samples in both labs

Caveats

-Panel was distributed mostly unblinded
-Small sample size
-Third lab failed to detect virus despite sensitive assay (me-note that NCI, the lab that didn't find it was the only one blinded)

 

[Cort]

Phase IIB

This is a nice setup..These samples never kissed the WPI's doorstep - so this is how they test if theres contamination at the WPI or at least in those original samples. If these samples turn up negative - then you have to start to think that these people don't have XMRV but their samples do....bad news.

On the other hand - its just for people isn't it and we know that sometimes it takes multiple blood draws to XMRV. We do know that most of these people have had their blood tested several times and WPI can consistently find it in their blood. What we on't know if their blood is being drawn several times or if the WPI has looked in the same sample several times. Hopefully it's the first.

This time EVERYTHING is blinded.

This is clearly a more important test than IIA.

Phase IIb Setup

XMRV-positive samples

-Blood collected into EDTA tubes by an independent phlebotomist at patients' home or work from the same 4 subjects. One patient had independently initiated ARV. (me-I don't think this could be Dr. Deckoff-Jones because I think she blogged that they started ARVs in March, rather than May.)

-The pedigreed negative subject used for the analytical panel and Phase IIa panel was bled by the same phlebotomist (to serve) as a control

-Phlebotomist directly suppled the samples to BSRI for processing

-Samples separated into tubes and were processed the same day, or left at 4 degrees C for 2 days

-Each sample was processed into PBMC, WB and plasma

Analysis

-Blinded panels were distributed by BSRI to WPI, CDC, NCI and Gen-Probe for testing. Two sets retained by BSRI to distribute for follow-up work as needed.

-Results were reported back to BSRI and decoded.

 

[Cort]

National Cancer Institute

The NCI, of course, was a co-author of the original paper.

They are still simply looking for the gag sequence - this was the main finding in the Science paper.

They didn't find anything at all - - that's not good. Gag is apparently the most trustworthy sequence, but when they actually went to the putatively positive patients and got their blood they couldn't find it...On the other hand they didn't find it the first time either, which makes one wonder why they would be able to find it now. ..

The NCI did not validate the gag findings in the original paper - the Cleveland Clinic did.

we isolated nucleic acids from PBMCs and assayed the samples for XMRV gag sequences by nested PCR (5, 6). Of the 101 CFS samples analyzed, 68 (67%) contained XMRV gag sequence. Detection of XMRV was confirmed in 7 of 11 WPI CFS samples at the Cleveland Clinic by PCR-amplifying and sequencing segments of XMRV env (352 nt) and gag (736 nt) in CFS PBMC DNA

But they couldn't find them now.

(If this was the CDC everybody would be howling - unfortunately it's not - this bug, for the umpteenth time, is not easy....).

Phase IIb NCI/DRP Results

Single-copy quantitative PCR assay for XMRV gag

-Plasma spiked with internal control virus and either extracted directly or ultracentrifuged before nucleic acid extraction using guanidinium isothiocyanate and used +/- RT step

-WB and PBMC extracted for DNA and RNA and used +/- RT step

All plasma and PBMCs samples at both time points (Day 0, 2) were negative

-Plasma internal controls for pelleting of virus and RT step were all in range

 

[Valb626]

One of the questions I have and hope we get an answer to tomorrow is whether NCI/DRP is different from NCI/Ruscetti (on a later slide re: serology results).

So confusing STILL!

 

[anciendaze]

Information about Subject 1:

XMRV PCR positive 5/5 (nested)
XMRV seropositive 5/5
XMRV culture positive 3/5

Not a CFS patient, but a family member, not on ARVs

This subject was particularly interesting. We have reports going back to DeFreitas' work that their strongest test results came either from people who were completely asymptomatic, or in remission. The problem of controls turning into patients, which suggests transmission, has plagued the field from the beginning.

 

[Cort]

The CDC

They were able to find XMRV at times in the samples sent directly from the WPI. Now can they find them in samples directly from the patients. If they do they validate the WPI's findings...if they don't that boosts the contamination theory....

They found nothing...

Thus far the gag sequence is not working out....

Phase IIb CDC Results

Multiple Assays for XMRV and generic MLV

-Plasma ultracentrifuged before nucleic acid extraction

-Plasma assayed with nested RT-PCR for XMRV gag and envelope and quantitative RT-PCR for MLV gag and integrase

-WB and PBMC assayed with nested PCR for XMRV polymerase and quantitative PCR for MLV protease

All plasma and PBMCs samples from both days were negative

-Plasma RNA controls in range

-WB and PBMC genomic DNA controls in range[/B]