from: Vivienne Hughes to: GUmail … · 2018-12-11 · Myalgia Widespread Pain Widespread Pain Widespread Arthralgia Pain Fatigue Fatigue, Sleep Fatigue

from: Vivienne Hughes to: GUmail date: Sun, Sep 16, 2018 at 11:03 PMsubject: Re: PP-Baraniukmailed-by: griffith.edu.au

Provocation Testing in CFS/MEJames N. Baraniuk, MDGeorgetown University, Washington DC USA

Provocation Testing in CFS/ME

James N. Baraniuk, MDGeorgetown University, Washington DC USA

[email protected]


• Hypothesis:

• 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.

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

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

Chronic

Multisymptom

Illness (CMI) 2

GWI

“Kansas” 3CFS

“Fukuda” 4FM 2010 17 FM 2011 ?? FM 1990 15

Tenderness

Musculoskeletal PainMyalgia Widespread

Pain

Widespread

Pain

Widespread

PainArthralgia

FatigueFatigue,

Sleep

Fatigue Fatigue Fatigue

SleepWaking

unrefreshed

Waking

unrefreshed

Post-exertional

malaise

Cognition,

Mood

Cognition, Mood

Neurological

Cognition Cognition Cognition

Depressed

Headache Headache

GastrointestinalSomatic

symptoms

Abdominal painRespiratory Sore throat

Skin Sore lymph nodes

≥1 chronic symptom

in ≥2 categories≥3 of 6 categories

Fatigue plus

≥4 of 8Severity scores Severity scores

Pain +

Tenderness

Defining CFS and its Differential Diagnosis

Center for Epidemiological Studies – Depression (CESD)

20 items scored 0 to 3 by severity in past week

Cut-off score ≥ 16 / 60This 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, AppetiteThe 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. PsycholMed. 1995 Sep;25(5):895-905. Review. PubMed PMID: 8588008.


4 Factors: Somatic, Depressed, Anhedonia, Interpersonal

24% of US population at risk for depression using total score (black) threshold of 16 / 60(NHANES & sedentary controls)

Median

Traditional threshold for Total CESD Score (black) = DepressionScore of 16 / 60 = 24%


4 Factors: Somatic, Depressed, Anhedonia, Interpersonal

94% of Depressed subjects in PROMIS studies ≥ 16 / 60

Total CESD Score (black) threshold of 16 / 60

Depression


4 Factors: Somatic, Depressed, Anhedonia, InterpersonalSC CFS GWI

High Somatic Domain Scores cause positive CESD in 54% of CFS

Depressed Depressed


• 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

Systemic Hyperalgesia in CFS, GWI and FM Females

0%

10%

20%

30%

40%

0 3 6 9 12

Fre

qu

en

cy

Dolorimetry (bins of 1 kg)

GWI n=68

CFS n=174

FM n=28

SC n=133

4.5 kg

0

0.2

0.4

0.6

0.8

1

0 0.2 0.4 0.6 0.8 1

Sen

siti

vity

1 - Specificity

GWI

CFS

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

MRI - Exercise Study to Model Exertional Exhaustion

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 1/3rd

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

MRI DAY 1 DAY 2 MRI LPQ H&P



Ceiling vs

FloorEffects

FunctionalDisordersMigraine

MRI: 3T Seimens TrimTrio, 32 element head coil, new PRISMABrain anatomy – voxel based morphometryMolecular spectroscopyResting state scan for Resting State NetworksCognitive 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


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


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

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

Dizziness After Exercise

Postural Orthostatic Tachycardia

Exercise-Induced Postural

Tachycardia

Postural Orthostatic Tachycardia

Exercise-Induced Postural

Tachycardia

Exercise increased Dizziness in 22/39 CFSPOTS did not explain Dizziness in CFS

Exercise caused symptoms that could not be explained by postural tachycardia

Dizziness After Exercise

Dizziness While Lying Down in 41% CFSExercise increased Dizziness in 22/39 CFS (56%)

POTS did not explain Dizziness before exercisePostural 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

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?)


HYPOTHESES:




4. Submaximal exercise on DAY 1 postural tachycardia in 1/3rd of CFS

5. Exercise worsens orthostatic intolerance (symptoms)





HYPOTHESES:




4. Submaximal exercise on DAY 1 postural tachycardia in 1/3rd




7. Cerebrospinal fluid contains CFS biomarkers


Cerebrospinal Fluid for Cytokines

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

• Targeted Biocrates 180 analytes• 2 significantly different

• C5-OH (C3-DC-M)• PC ae C44:4

Pearson Correlations

Positive Mode

Negative Mode

Unknowns in LC-MS-MS

Positive Mode: Pooled Nonexercise (white) vs. Post-exercise (grey)Acrolein suspected Positive Mode @ 456 sec

18 Negative Mode Peaks at 249 sec

e.g. M460T249nm

Distinguish CFS from GWI in Nonexercise specimens

Mean ± SD

No exercise Post-exerciseTargeted Metabolomics

Control

CFS

GWI

GWISTART

GWISTOPP

Control

Exercise

Lumbar Puncture Cerebrospinal fluid miRNA

DNA genome & genes

pre-mRNA

Spliceosome & Processing

Mature mRNA miRNA~22 ntd

Mature mRNAmiRNA

miRNA binds mRNAmRNA destroyedNo proteinTranslate mRNA

into protein

miRNAs fine tuneprotein expression

In general, miRNAs were reduced

after 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

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

miR-328

miR-608

miR-200a-5p

miR-93-3p

miR-92a-3p

Lumbar Puncture Cerebrospinal fluid miRNA DIANA for gene targets

No Exercisesc0 = sedentary controls

cfs0 = CFS no exercisegwi0 = GWI with no exercise

Post Exercise – After DAY2 ExericseSC = sedentary controls

CFS = CFSSTART = GWI Stress Test Activated Reverisible TachycardiaSTOPP = GWI Stress Test Originated Phantom Perception

In general, miRNAs were equivalent within No Exercise and Post-Exercise specimensmiRNAs were higher before exercise and (cfs0>CFS, gwi0>START, gwi0>STOPP)

[except for sc0>SC and SC>sc0]

# GO Category p-value Genes #

miRNA

1 nucleoplasm (GO:0005654) 8.19E-05 8 4

2 ribonucleoprotein complex

(GO:0030529)

0.00067 5 4

3 organelle (GO:0043226) 0.00067 16 4

4 mitotic cell cycle (GO:0000278) 0.0020 4 3

5 cytosol (GO:0005829) 0.0020 9 4

6 cellular component assembly

(GO:0022607)

0.0047 6 4

7 gene expression (GO:0010467) 0.0055 4 4

8 RNA binding (GO:0003723) 0.0056 7 4

9 cellular nitrogen compound

metabolic process (GO:0034641)

0.0056 10 4

10 exoribonuclease activity,

producing 5'-phosphomonoesters

(GO:0016896)

0.0093 1 3

11 cytoplasmic ribonucleoprotein

granule (GO:0036464)

0.0093 2 4

12 DNA replication initiation

(GO:0006270)

0.0095 2 3

13 ATP-dependent chromatin

remodeling (GO:0043044)

0.0095 2 4

# KEGG pathway p-value #

genes

#

miRNA

1 Fatty acid

biosynthesis (hsa00061)

3.12E-36 1 2

2 Fatty acid

metabolism (hsa01212)

2.46E-13 2 2

3 Adherens junction (hsa04520) 0.000256 7 4

4 Lysine degradation (hsa00310) 0.000485 4 3

5 Transcriptional misregulation

in cancer (hsa05202)

0.000515 7 4

6 Viral myocarditis (hsa05416) 0.003162 7 4

7 Cell cycle (hsa04110) 0.005299 11 4

Combinations of miRNAs DIANA Intersection of Pathways Weighted Targets

# Modules of target proteins with linkers Top pathway for each moduleCy0 ACTB, CDC42, ELK4, FASN, FYN, IGF1R, IQGAP1, PTPRJ, SETD7, ZNF703

(Linkers: CCT8, CSNK2A2, CTNNB1, MAPK3, STAT3)Adherens junction

Cy1 BAG6, DYRK1A, EWSR1, H3F3B, KMT2D, SCD, SIN3A(Linkers: EP300, HIST1H4A, RXRA)

Transcriptional misregulation in cancer

Cy2 DDX5, HNRNPC, NCL, PCBP2, PRPF8, SCARB2, TCF3(Linker: HSPA8)

Processing of Capped Intron-Containing Pre-mRNA (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

Ingenuity Pathway Analysis (IPA)

Cytoscapemodules


HYPOTHESES:




4. Submaximal exercise on DAY 1 postural tachycardia in 1/3rd of CFS




7. Cerebrospinal fluid will contain CFS biomarkers



• 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?

Thank you for the invitation, opportunity,

and fellowship

James N. Baraniuk MD

Georgetown University, Washington DC

[email protected]

Documents

from: Vivienne Hughes to: GUmail … · 2018-12-11 · Myalgia Widespread Pain Widespread Pain Widespread Arthralgia Pain Fatigue Fatigue, Sleep Fatigue