Bob
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Considering that Dr Snell's latest paper supersedes his 2005 paper which is cited in the ME primer, and the results for VO2 peak do not seem significant in the latest paper (if I've interpreted it correctly), do you think the primer now needs updating?Without ever naming it, Dr. Unger is referring to the ICC domain of post-exertional neuroimmune exhaustion: “When an exercise test was given on two consecutive days, some patients experienced up to a 50% drop in their ability to produce energy on the second evaluation [62].” PENE is described as the cardinal feature of ME, a subset that should be treated as separate and distinct from CFS. Dr. Unger must be familiar with the test for PENE prescribed by the ME Primer:
PENE: A 2 consecutive day comprehensive 8-12 minute cardiopulmonary exercise stress test (measuring heart, lung, and metabolic function) - only ME patients have significantly worse scores the second day & abnormal recovery from exertion. * Exercise tolerance test with expired gas exchange - (2 consecutive days) – measure cardiovascular, pulmonary & metabolic responses at rest & during exercise: □ peak oxygen consumption VO2 or VO2 at anaerobic threshold (AT) - decline of 8% or greater on test 2 indicates metabolic dysfunction, □ post-exercise blood analysis - increase in sensory, adrenergic and immune genes - increase in metabolite receptors unique to ME
By tapping the domains of earlier case definitions, Dr. Unger is turning the clock back a decade, despite professing:I share your concern about patient heterogeneity. My question is whether any one case definition is going to solve the problem. Part of what I think we need to do is decide what the measures are that are going to yield us meaningful subgroups of this illness. I think even the Canadian case definition allows for heterogeneity.
But she's actively trying to define subsets, based on her data. Yes, I agree that she needs to include objective tests. But if she does include objective tests, then I can't fault her approach of actively trying to define subsets, with large amounts of data. That is exactly what is needed, in my opinion. Of course it all depends on the honest intentions of the investigators, which is yet to be proven.
Assuming honest intentions, for the sake of discussion, how would such a study not be beneficial, in your opinion, if it included two day CPET tests?
Agreed, as long as Unger is aware of Dr Snell's 2013 CPET research results, and not just the 2005 paper which is referenced in the ME primer. But I still think her post-exertion cognition tests may prove to have some merit. Cognitive tests are a fairly objective indicator of cognitive performance, aren't they? (I do not know much about the merits of cognitive tests, but I assume that they can be helpful objective indicators of cognitive function. And if they are, then they may provide a useful objective indication of post-exertional symptom exacerbation.)Dr. Unger could address her research questions by gathering the data that the Stevens Protocol provides.