Talk:Myalgic encephalomyelitis/chronic fatigue syndrome/Archive 18

New edits
I generally agree that most of the newer edits by Doc James improved the article but I have disagreements with some. I wanted to discuss them to see if there is consensus.


 * I don't believe serious symptoms in the first sentence of the lead is as accurate as debilitating symptoms. A majority of the recent reviews and guidelines seem to use the wording "debilitating symptoms" to describe the illness.


 * I disagree with separating the Oxford criteria from the other criteria as they are all used for clinical and research purposes. I believe they should be recombined and possibly the title renamed to better describe the section.

There are some other wording changes that may improve the article here and there. Now that the sections are rearranged and simplified it has exposed other weaknesses in the article. But these seem to be minor and in time copy editing should fix these. Good job Doc James. Thanks. Ward20 (talk) 15:31, 7 May 2015 (UTC)
 * Agree that overall this is an improvement - although it would have been good if DocJ could have at least outlined his strategy on this page given the scale of changes. I agree with Ward that 'debilitating symtoms' is a far more useful term. As regards the split of the Oxford reference - I think that is wholly logical and I would keep DocJ's edit; Oxford was developed specifically for Research and as far as I'm aware has never been expressly employed in a clinical setting. I haven't been able to go through all the changes,although something did stand out as problematic (not sure if new or old) is:


 * Cognitive behavioural therapy (CBT) and graded exercise therapy (GET) have shown moderate effectiveness for many people in multiple randomized controlled trials. Many seems far too ambiguous, certainly PACE only showed notable benefit for a minority.


 * I also agree with Ward that the new presentation shows up deficiences in the article. Some sections look somewhat bloated relative to the information given the reader, and it might be worth looking at reductions where daughter articles exist.--In Vitro Infidelium (talk) 17:24, 7 May 2015 (UTC)
 * Sure so I had two goals
 * 1) to order this article to match the outline used for other conditions per WP:MEDMOS
 * 2) to simplify the language to make the lead more accessible specifically Doc James  (talk · contribs · email) 20:38, 7 May 2015 (UTC)
 * How about rather than "CFS is a medical condition characterized by significant symptoms, including fatigue, that lasts for a minimum of six months in adults (and 3 months in children or adolescents)."
 * "CFS is a medical condition characterized by symptoms, including fatigue, that lasts for a minimum of six months in adults (and 3 months in children or adolescents). These symptoms are to such a degree that they limit a person's ability to carry out ordinary daily activities."
 * rather than use the complicated word "debilitating" we can simply write what it technically means "limited ability to carry out ordinary daily activities"
 * By the way the new MedlinePlus content is in the public domain and therefore we can use it verbatim. They have partly dumped ADAM. Doc James  (talk · contribs · email) 20:43, 7 May 2015 (UTC)


 * I suggest "CFS is a "devastating and complex" medical condition characterized by fatigue and other symptoms that substantially limits a person's ability to carry out ordinary daily activities. The illness must last for a minimum of six months in adults (and 3 months in children or adolescents) in order to receive a diagnosis." Ward20 (talk) 10:32, 8 May 2015 (UTC)
 * That is more complicated IMO. Also does not have a very encyclopedic tone. Doc James  (talk · contribs · email) 17:06, 8 May 2015 (UTC)


 * I think the term "devastating" is too subjective, and the disease varies from one person to the next anyway. While certainly life-altering for me, I think "devastating" would be a bit strong of a term, while others who are permanently bed-bound most certainly are devastated by the disease. I have no objections to the term "complex", though—after all, if it were simple, we'd know exactly what it is by now—and I like the idea of including wording that specifically references the change to ordinary daily activities, since even milder cases of it usually have a notable impact in that area. – Robin Hood  (talk)  19:24, 8 May 2015 (UTC)

OK, here is a mash up for consideration: "CFS is a complex medical condition, characterized by fatigue and other symptoms, that lasts for a minimum of six months in adults (and 3 months in children or adolescents). These symptoms are to such a degree that they limit a person's ability to carry out ordinary daily activities."

Ward20 (talk) 07:03, 9 May 2015 (UTC)
 * Could we simplify it a little further to "CFS is a complex medical condition, characterized by fatigue and other symptoms, that lasts many months. These symptoms are to such a degree that they limit a person's ability to carry out ordinary daily activities."
 * We can than describe the exact number of months in areas as the exact number of months IMO is not the most important. Doc James  (talk · contribs · email) 16:04, 9 May 2015 (UTC)


 * I'd suggest changing the wording to "long-term fatigue and other symptoms", if we're going to simplify it to that extent. As worded there, it sounds like the disease comes for a few months and then goes away again, which obviously isn't the general case. – Robin Hood  (talk)  17:42, 9 May 2015 (UTC)


 * Yes, using the wording, "long-term fatigue and other symptoms" I would eliminate "that lasts many months" as that term would then be redundant and possibly ambiguous as to the illness duration. Ward20 (talk) 18:01, 9 May 2015 (UTC)
 * Sounds good. Doc James  (talk · contribs · email) 18:12, 9 May 2015 (UTC)


 * The problem with that suggestion above is that 'Myalgic Encephalomyelitis' now redirects here. That is not long term 'chronic' fatigue. It is exhaustion that comes and goes -dependent on the amount of activity, both mental and physical. We have both 780.71 & G93.3 locked into one article. It would be better to separate them again. One code, one unique article article. Otherwise, it continues to go against, all we have been taught about about correct nomenclature & taxonomy. That established form is the correct way (as an encyclopaedia) to organize things. --Aspro (talk) 13:33, 10 May 2015 (UTC)


 * This suggestion has been brought up many times in the past. The problem is that there's no broad agreement that ME and CFS are two separate things. Before we can entertain separating the two, there would have to be significant support for the idea in the medical literature from government health agencies, in the various journals, that sort of thing. The ICD itself doesn't make the clear distinction, and the two codes you're referring to are in different versions of it, so we can't say that they're two different entries for two different diseases. Also, contrary to your assertion, for many of us, there is chronic fatigue (and other chronic symptoms, of course) which gets a lot worse when we exercise. The new SEID criteria, for example, even suggests that "The diagnosis of ME/CFS should be questioned if patients do not have these symptoms at least half of the time with moderate, substantial, or severe intensity." It's been a while since I've read them, but as I recall, the CCC and ICC allow for both intermittent and chronic illness, and make no distinction between them. – Robin Hood  (talk)  15:32, 10 May 2015 (UTC)


 * Is it any wonder that “This suggestion has been brought up many times in the past.”? This redirect (ME to CFS) was done some years back, when a number of psychiatrist (who have become known as the Wesley School) gained some traction in convincing people that ME was psychological in origin. Yet there was never any logical reason offered, to lump CFS (associated with cancer etc.,) with and other codex designations. Prof. Wesley has now excused himself from this  and so we should re-split the articles. It will make the wording easier. Trying to blend a conclusion from two different premisses, was discovered by the Greek philosophers to be impossible. Now that,  that Prof (that original promoted  this),  has backed-out himself, from wanting to lump all these sign and symptoms together -then what is the point of WP still lumping everything   together? This problem didn’t exist before the redirect. The redirect only serves to confuse. So why not go back to where we were before? To say this problem has cropped many time since the redirect is maintaining a circular argument. --Aspro (talk) 16:05, 10 May 2015 (UTC)

"characterized by long term fatigue and other symptoms" does not mean that "long term fatigue" must always be present. It is just a common symptom. Both are two such a degree that functioning is affected. So the text we have is correct for both terms and thus I see no reason to separate. We can discuss the finer details in the body of the article. The lead is for generalities. Doc James (talk · contribs · email) 16:19, 10 May 2015 (UTC)


 * Many a malady has over-lapping signs & symptoms. Are you suggesting, that using your logic, I can do a blitz on WP and redirect multiple article with over lapping symptoms? As to “We can discuss the finer details in the body of the article.” Chronic_fatigue_syndrome just takes up 4 sentences! I see where you coming from, yet the problem (in part) lays with the word 'Syndrome'. CFS is not a pacific  disease. Denying finer taxonomies their own article is taking a step backwards and sitting on it. The article CFS would make more 'rational' sense if included  See also to the other codexes and definitions. If we were only to stop bitching amongst ourselves, an epidemiologists (or two or three) may be willing to contribute. But professionals  steer clear of articles where they find, that as anybody can contribute to WP,  their own contributions get deleted as fringe because other editors were only exposed to  the superficial, simplistic explanation in med skool. I agree with Doc James that we should discuss this in finer detail – yet, for that to be productive, we need to have those discussions in the right article talk pages.  Otherwise we might as well say to all the WP editors  they can forget nomenclature & taxonomy,  and just edit in a way that makes them feel warm inside.  The reason that “This suggestion has been brought up many times in the past” is because some  people 'care' and are willing to question past dogma and bring their learning up-to date. Split the article back again and then see if anyone can come up with a justifiable reason to bring about a consensus to redirect. --Aspro (talk) 20:11, 10 May 2015 (UTC)


 * Actually, I never said anything about the previous redirect, I said that the suggestion had been brought up in the past. I'm aware that there was redirect some time ago, and I'm aware that, both currently and in the past, there have been people editing the wiki that have both pro-physiological and pro-psychological viewpoints. I believe, in fact, that most of us currently monitoring the article believe in a physiological basis for the disease (i.e., we're not of the Wessely school). None of that has anything to do with what the medical literature says, however. If you want to suggest a split, you need to find reliable medical literature that says they're two clear and distinct diseases. It's really that simple. The ICC states that those with ME should be excluded from CFS, which is an excellent starting point, but one diagnostic criteria out of some twenty or more is not sufficient to justify the split. So, what other significant medical literature or bodies suggest that ME and CFS are separate? If you can find a couple of things like that that comply with Wikipedia's requirements, the split can happen anytime. In the absence of such evidence, however, Wikipedia's own rules say that the split can't happen. – Robin Hood  (talk)  06:13, 11 May 2015 (UTC)


 * Aspro, you brought up the same topic here in February and the same arguments are being rehashed. Right now there seems to be more reliable sources equating cfs and me than separating them. If you can prove otherwise than great, produce the sources.


 * There is a chance this topic will heat up in the medical literature in October of this year when ICD-10-CM is implemented, and USA doctors will have to choose between diagnosing one or the other because the two diagnosis codes are mutually exclusive. Note it lumps and Chronic fatigue, unspecified and Chronic fatigue syndrome NOS together which is bound to cause issues:


 * "G93.3Postviral fatigue syndrome
 * Benign myalgic encephalomyelitis
 * Excludes1:chronic fatigue syndrome NOS (R53.82)"


 * "R53.82Chronic fatigue, unspecified
 * Chronic fatigue syndrome NOS"


 * I would advise either presenting reliable sources to back up your suggestion now, or waiting until After October to see if more reliable sources back your suggestion then. Ward20 (talk) 09:12, 11 May 2015 (UTC)

Thanks to Doc James for explanation of strategy which makes full sense of the changes. @Aspro - we've been through this at length previously. Let's be absolutely clear - there never has been a WP article based on ICD-9-CM that was separate from an article based on ICD-10 or any previous ICD iteration. There were, some years ago seperate CFS and ME articles but both referenced ICD-10 and ICD-9-CM, and neither article would now meet current WP standards. Without any MEDRS to base a split on this is a dead issue unless perhaps, as Ward20 suggests something arises from conflicts within the operation of ICD-10-CM. Given that ICD-11 is in preparation, that it will be a more complex iteration than ICD-10, and that there is a potential for SEID to enter classification in both ICD-11 as well as in ICD-10-CM annual updates, setting out to create separate CFS and ME articles at this point would seem foolish given the level of effort involved, and that major re-evaluation may be required on a continuing basis over the next one to two years. --In Vitro Infidelium (talk) 17:28, 12 May 2015 (UTC)


 * Aspro is right, ME/PVFS/Iceland disease/Akureyri disease should not redirect to the CFS article. WHO ICD G93.3 should have its own article. The former mentioned disease names/descriptions/ICD entries existed long before CFS did and it makes no sense to subsume them under what is clearly an ICD-9-CM CFS based article. It leads to ridiculous confusion, like the box on the top of the page listing classification. It lists the ICD-9-CM code for CFS but then the WHO ICD-10 code for PVFS. As mentioned above, this should be changed soon to reflect the upcoming ICD-10-CM classifications (to be clear, it should say ICD-9-CM 780.71 and ICD-10-CM R53.82), and clearly I think the fact that the ICD-10-CM lists them as separate, exclusionary diagnoses supports the creation of a separate PVFS/ME article. Don't hold your breath for ICD-11, it's a long ways off and ICD-10-CM will likely be in use for a long time to come. Anal0gue (talk) 19:19, 17 June 2015 (UTC)


 * Again, where is the evidence? I know it's the in thing in the ME/CFS activist community to try to separate ME and CFS, but there's really no broad agreement on whether they're one disease, two, or a hundred. The fact that the ICD and International Consensus Criteria suggest a split is certainly a step in that direction, but we're not at the point yet where we can justify a split based on Wikipedia's guidelines. In order to do that, there needs to be broad agreement that ME and CFS are clearly separate things, and there needs to be supporting evidence. Otherwise, we end up creating a POV fork, and simply duplicating most of what's here on both pages. When there's solid evidence that they're two separate conditions, that's when we split them on Wikipedia. – Robin Hood  (talk)  21:46, 17 June 2015 (UTC)


 * It's also the "in thing" in research to try and separate them because it's an important question that needs to be answered. Leonard A. Jason has been doing work in this area and reports that ME criteria select out a different patient group than CFS criteria. That's pretty compelling evidence for a difference. Without a biomarker we'll never be able to definitely say they're different. It's also a bit of a double standard. While I don't have any solid evidence that they are different to support a split, you don't have any solid evidence that they are the same to maintain a single article. With the way this article is now, it's too narrow of a POV, only focusing on US Fukuda CFS. I imagine it would rustle everyone's jimmies if people started adding ME specific information in this article and it would be rolled back, much like if someone tried to populate the ME article with ME specific information. In this way, all information about ME is unfairly suppressed. It has nothing to do with activism. Anal0gue (talk) 19:53, 19 June 2015 (UTC)


 * Yes, you're right, it is a very important question, and I firmly believe that different conditions will be split off in the future as evidence becomes available. Various pilot studies that I've seen over the years I've had this have suggested that what currently gets grouped under the term "CFS" may be as many as seven or eight different conditions, while others suggest that it's just one, with a very broad array of symptoms. Anyone looking at forums will see some fairly substantial variations between patients, which is why I personally believe it's more than just one thing, but I can't prove that, and so far, neither has anyone else. Even those who are proponents of separating ME have yet to prove that the encephalomyelitis occurs in all cases of CCC/ICC-defined ME. Last I heard, there were only one or two very preliminary studies that suggested that that was the case, not anything resembling proof. As for selection criteria, that's a no-brainer, though certainly Leonard's work is going a long way to formalizing the results. The simple fact is that if the criteria always selected the same groups, the debates over what criteria to use wouldn't be happening and a lot more progress would've been made on this/these condition(s) by now.


 * As for a double-standard, it's not at all. Most of the literature currently still treats them as a single entity. Can they prove it? No, of course they can't, because we don't have any kind of known etiology at this point. But since the literature mostly treats ME/CFS as a single thing, so must we. If the majority of the literature starts treating them as clearly separate things, or better yet, clear proof comes out that they're separate things, then Wikipedia will absolutely follow suit and I'll be the first to propose/support such a split. Given that they're mostly being treated as a single thing right now, by all means, go ahead and add whatever ME-specific stuff you can find. Just be aware of the restrictions set out by WP:MEDRS, which require that studies by reliable, secondary sources, for the most part.


 * Finally, as for Fukuda-defined ME/CFS, I'm curious where you see that. If the scope of the article is in any way too narrow, then by all means, we should expand it to ensure that we're presenting a clear, accurate picture of things. Unfortunately, most of the times people have brought forward that suggestion, it's based on whatever preliminary research or unproven assertions (even if those assertions are by experts in the field) are currently popular in the forums and/or the activist community. Wikipedia doesn't work that way, one of its major precepts being verifiability, not truth. – Robin Hood  (talk)  20:34, 19 June 2015 (UTC)


 * Also, can you point me to which Wikipedia guideline would be against a split of the two? As far as I can tell, this is a pretty unique scenario, there don't seem to be many diseases with more than one (or in the case of ME, 7+ names). I actually spent almost an hour going through the ICD-10-CM and WHO ICD-10 looking for another example disease so I could see how it was handled on WP but couldn't find one. It's also a little weird to me that SEID redirects to the CFS article. It's going to have its own, likely separate ICD code. It has it's own history and diagnostic criteria. The whole point of the creation of SEID was to move away from the inaccurate, stigmatic CFS name. And here we are redirecting SEID to CFS. Anal0gue (talk) 00:29, 20 June 2015 (UTC)


 * Let me come at this from another angle: let's say a split happens. Without question, on both the ME and CFS pages, we would want to define how the two are different from one another. Provide the text for that distinction, with reliable references from sites such as PubMed. (Sorry, looks like we just cross-posted, I'll respond to the above message in a sec.) – Robin Hood  (talk)  00:33, 20 June 2015 (UTC)


 * Why does it have to be a medical literature based distinction, can't it be a historical distinction? Wikipedia is an encyclopedia, not a medical text book. There is a history and information about ME that existed for decades before CFS was even invented. Shouldn't that information exist in an encyclopedia, underneath the appropriate heading? Anal0gue (talk) 00:54, 20 June 2015 (UTC)


 * Here is the text for the distinction, right out of the ME ICC paper, indexed on Pubmed:
 * ″The label ‘chronic fatigue syndrome’ (CFS) has persisted for many years because of the lack of knowledge of the aetiological agents and the disease process. In view of more recent research and clinical experience that strongly point to widespread inflammation and multisystemic neuropathology, it is more appropriate and correct to use the term ‘myalgic encephalomyelitis’ (ME) because it indicates an underlying pathophysiology. It is also consistent with the neurological classification of ME in the World Health Organization’s International Classification of Diseases (ICD G93.3).″
 * Yes, a lot of the literature uses the terms interchangeably, but that doesn't make it right. Strictly speaking, if a paper uses one of the CDC criteria, it should say CFS. If it uses the CCC, it should say ME/CFS. If it uses the ICC, it should say ME. If it uses the IOM criteria, it should say SEID. Anal0gue (talk) 01:12, 20 June 2015 (UTC)

I pointed you to the relevant guideline above: POV fork. You're certainly correct that this is a fairly unusual situation. The only similar situations I can think of went in the opposite direction, merging two diagnoses into one. The first is sociopathy vs. psychopathy. Currently, those are the same article because the popular belief in psychology is that they are. Twenty or so years ago, they would likely have been two separate articles. Another one is the debate about high-functioning autism vs. Asperger syndrome. Amusingly, despite the DSM-5 doing away with the diagnosis of Asperger's, we still have two separate articles. I haven't looked, but I wouldn't be surprised if those pages have had a lot of similar split/merge debates because I believe they're both still considered contentious issues.

As far as SEID goes, that's definitely going to be another one to keep our eyes on. At the moment, it redirects here because even though the different diagnostic criteria come up with different results, they're all trying to evaluate the grouping known broadly as CFS, of which ME and/or SEID may or may not be a part. If the term SEID becomes accepted and widely used, and even more so if it defines a clear disease process that can be distinguished from other things currently grouped under the CFS umbrella, then I think we could entertain renaming or splitting the article. Right now, though, SEID is only a proposed name from an American institution and the criteria for it still need to be evaluated for how effective they are at identifying patients.

Responding to your next post, we do have some of the historical definitions under the History section, plus of course that links to an entire article about the history. If we ever do split this article, some of that would definitely go into the new one and quite possibly end up being removed from here, depending what is seen as being included/excluded in CFS at that point.

And for your most recent post, I'll let others comment, as I'm less neutral on that issue than someone else might be (amusingly, I'm both for and against a split, simultaneously, which is a very confusing position to have). Even with the ICC bit that you quoted, though, that would support a renaming, but not necessarily a split. – Robin Hood  (talk)  01:19, 20 June 2015 (UTC)


 * Another reason not to split at this time is the 2015 study Distinct plasma immune signatures in ME/CFS are present early in the course of illness. Some definitions may not be describing different illnesses, but may instead be selecting different phases of the same illness. In any event the material that is now being discussed can be used in the article Clinical descriptions of chronic fatigue syndrome with secondary sources showing how the people described vary with the definitions used. That article is in need of an overhaul anyway. Then if secondary sources start to split off subgroups per various definitions, new articles could be developed from there.Ward20 (talk) 08:02, 20 June 2015 (UTC)


 * The Lipkin/Hornig study is not a very compelling argument for ME and CFS being the same thing. The inclusion criteria for patients in that study was Fukuda *and* CCC, plus they had to have developed the disease following a viral illness. The last part is key and probably heavily selected out the real ME (aka post-viral fatigue syndrome) patients. There is a new paper out by Twisk that concludes that ME and CFS criteria define two overlapping but distinct clinical entities. He states plainly that ME is not equivalent to CFS. Anal0gue (talk) 01:13, 24 June 2015 (UTC)

01:11, 26 November 2015 (UTC)

Has CFS been researched extensively or not?
The article claims that CFS has been extensively researched. The source speaks of a "vigorous search". It's hard to reconcile this statement with reality as CFS is an area of research that is severely underfunded (annual NIH budget of $5 million ). A source that supports the statement that there is actually a lack of research is the IOM report: "While there was sufficient evidence with which to carry out the first steps of its task, the committee was struck by the relative paucity of research on ME/CFS conducted to date in many areas related to this disorder. Remarkably little research funding has been made available to study the etiology, pathophysiology, and effective treatment of this disease, especially given the number of people afflicted. Thus, the committee was unable to define subgroups of patients or even to clearly define the natural history of the disease. More research is essential." A number of researchers have also written an open letter to senator Mikulski about their difficulties in securing funding for CFS research. They write that CFS is massively underfunded compared to other diseases of similar prevalence and severity. — Preceding unsigned comment added by Abmayer (talk • contribs)
 * I'm not sure "extensive" necessarily implies "sufficient". A Google Scholar search for papers with the term "chronic fatigue syndrome" in the title yields thousands of results -- that seems sort of extensive to me.  Can you suggest an alternate wording? Looie496 (talk) 13:06, 25 November 2015 (UTC)

A google scholar search for "multiple sclerosis" or "rheumatoid arthritis" yield over a million results for both. MS has a NIH budget of about $120 million. Research into CFS is certainly not extensive if compared to efforts into other diseases. I don't think alternative wording is appropriate - the statement is just wrong. Abmayer (talk) 13:18, 25 November 2015 (UTC)
 * After looking it over, I agree with you that the phrase "despite extensive research" should be removed, as it is somewhat misleading and doesn't contribute anything the sentence needs. I won't make that edit immediately though, so other editors can express their opinions without anything that looks like edit-warring. Looie496 (talk) 13:58, 25 November 2015 (UTC)


 * The source on which we currently rely http://www.cdc.gov/cfs/general/index.html uses the word vigorous rather than extensive. I've edited the article to change extensive to vigorous so that at least we can talk about the appropriatness of quoting the source rather arguing over an issue of interpreted accuracy. The source actually says: Despite a vigorous search, scientists have not yet identified what causes CFS. This doesn't precisely equate to the text as it now stands which is The causes and mechanisms of chronic fatigue syndrome are currently unknown, despite vigorous research. If there are still concerns about the current text then I suggest either quoting from the source directly or else finding an alternative source(s) which has the validity to match the CDC statement. --In Vitro Infidelium (talk) 15:26, 25 November 2015 (UTC)


 * The issue remains that talking about a vigorous search is misleading because people will interpret it to mean that a lot of research has been and is being done. Which is not the case. Abmayer (talk) 16:47, 25 November 2015 (UTC)


 * I would agree with Looie that it doesn't really contribute much to the sentence, and that a "vigorous search" for the cause doesn't quite equate to vigorous/extensive research into the causes and mechanisms. There's really nothing lost by simply removing that part of the sentence.


 * I've gone ahead and cut the sentence as there appears no strong argument to retain vigourous/extensive. I have also cut the word 'mechanisms' because that doesn't appear in the source, the shortened sentence does reflect the CDC page, albeit without the 'vigorous' moderator. --In Vitro Infidelium (talk) 10:04, 26 November 2015 (UTC)

New Source for diagnosis and management
http://www.degruyter.com/view/j/reveh.2015.30.issue-4/reveh-2015-0026/reveh-2015-0026.xml?format=INT

Abstract only available on open access. --In Vitro Infidelium (talk) 13:08, 29 November 2015 (UTC)

Pathophysiology IOM as source
I'm also unhappy with the pathophysiology section of this article because it doesn't really summarize what is known about pathophysiology. The part about causes (pathiogenesis) here is also borderline off topic. Pathophysiology is about the abnormalities that can be found in patients. Compare this to the pathophysiology section of Alzheimer's disease (https://en.wikipedia.org/wiki/Alzheimer's_disease#Pathophysiology). Besides the HPA axis stuff and abnormal response to exercise, there is also reduced NK function, and multiple forms of orthostatic intolerance (postural orthostatic tachycardia syndrome, neurally mediated hypotension, orthostatic hypotension).
 * I've taken the liberty of splitting AB Mayers post (follows) from the "extensive research" issue. IOM certainly seems to offer an opportunity to expand the Pathophysiology section and it will be easier to address that properly if it is separated from the semantic questions of vigorous versus extensive.--In Vitro Infidelium (talk) 15:44, 25 November 2015 (UTC)

The IOM report on orthostatic intolerance: "Sufficient evidence indicates a high prevalence of orthostatic intolerance in ME/CFS, as measured by objective heart rate and blood pressure abnormalities during standing or head-up tilt testing or by patient-reported exacerbation of orthostatic symptoms with standing in day-to-day life. These findings indicate that orthostatic intolerance is a common and clinically important finding in ME/CFS."

The IOM report on post-exertional malaise: "Several studies have found that, despite meeting objective indicators of maximal effort during both CPETs, ME/CFS patients have significantly lower results on CPET 2 than on CPET 1 on one or more of the following parameters: VO2max (Keller et al., 2014; VanNess et al., 2007; Vermeulen et al., 2010), VO2 at ventilatory threshold (Keller et al., 2014), and maximal workload or workload at ventilatory threshold (Keller et al., 2014; Snell et al., 2013)."

The IOM report on NK cell function: "The committee’s literature review yielded data demonstrating poor NK cell cytotoxicity (NK cell function, not number) that correlates with illness severity in ME/CFS patients and could serve as a biomarker for the severity of the disease, although it is not specific to ME/CFS."

What about cytokines, oxidative stress and genetics? Oxidative stress and genetics are mentioned in the context of etiology, not pathophysiology, so it's off topic as far as I'm concerned. The cytokine findings have been inconsistent, with results all over the place. There is one recent study by Lipkin which reported a specific pattern but I don't we need to mention this.

So I'd suggest rewriting the first paragraph to something like this:

The pathophysiology behind chronic fatigue syndrome is only understood in part. The disease is associated with abnormal immunological response to exertion, reduced ability to recover from exertion, neuroendrocrine abnormalities, reduced NK lymphocyte function, and forms of orthostatic intolerance including postural orthostatic tachycardia syndrome, neurally mediated hypotension, orthostatic hypotension.

After the opening paragraph we can then describe and explain these abnormalities a bit more in detail. Abmayer (talk) 15:20, 25 November 2015 (UTC)


 * I would like to invite other editors to comment on this so that a consensus can be reached. Abmayer (talk) 11:49, 28 November 2015 (UTC)


 * Before going further we need some consensus on whether the IOM report actually meets WP:MEDRS. It was not subject to a peer review that informed editorial oversight, however it was eminently reviewed in draft: https://www.ncbi.nlm.nih.gov/books/NBK284901/ . My view is that as the process involved was that approved by the US National Research Council's Report Review Committee that the report does indeed meet WP:MEDRS but until now I don't think there has been any clear agreement on this. --In Vitro Infidelium (talk) 17:51, 29 November 2015 (UTC)


 * Any objections to the IOM report as reliable source, or to the proposed changes? Abmayer (talk) 09:22, 2 December 2015 (UTC)


 * The IOM report is certainly a reliable source, but if we're going to use it we need to be clear that it defines a new entity (SEID) which is not an exact equivalent of CFS, as it has more specific diagnostic criteria. Looie496 (talk) 12:30, 2 December 2015 (UTC)


 * The IOM report examined the evidence base on ME/CFS. In addition it also proposed the SEID case definition and name. The two are indepedent. I do agree though that it would be useful for clarity to distinguish between the various case definitions better. Abmayer (talk) 14:28, 2 December 2015 (UTC)

Agreed SEID is only a part of the IoM report and only a small section of it is reliant on the SEID definition. There's little more that the article can say about SEID until(if) it is appraised in relevant journals. We do need to be cautious how we use the IoM as not all sources it uses may meet with WP criteria, and the related IoM text itself may not explicitly meet the point being addressed meaning we will need to go to the quoted material. A problem with using the IoM extract as the hanger paragraph for the pathology section is that the extract is heavily focussed on SEID, such that anyone following the ref will find something that is largely about SEID and not ME or CFS - this is perhaps what Looie was referring to ? The IoM should certainly be mined for pathology refs but it requires more than garnering some terminoogy from the extract - see history below. --In Vitro Infidelium (talk) 10:55, 3 December 2015 (UTC)

I've gone ahead and made the proposed changes. I think there is some room to add more material. Does anyone feel that any findings are missing? Should we be more specific about the autonomic dysfunction (orthostatic intolerance etc.)? Abmayer (talk) 20:30, 5 December 2015 (UTC)


 * Yes, it might be worth adding info about the ANS if you can find a good review. Also remember to update the pathophysiology sub-article. --sciencewatcher (talk) 20:34, 5 December 2015 (UTC)


 * I'll get around to update the pathophysiology article as well. And maybe explain the autonomic dysfunction a bit more in detail. Abmayer (talk) 21:42, 5 December 2015 (UTC)


 * @Abmayer.Could you identify more closely the sections of the IoM Report you are referencing. Simply using the front page URL and PMID is too vauge. If referencing the hard copy it would be acceptable to use the page number, with th online version you could use the relevant URL; you'll need to go to the text you are relying on and check the URL for that section. Without clarity in what part of the source is being relied upon the edits are unlikely to be sustainable - I have tried to track down where the IoM supports your edits and it is not obvious to me. Remember the IoM is only one source and Wikipedia requires a balance of sources. --In Vitro Infidelium (talk) 10:37, 6 December 2015 (UTC)


 * I have changed the refs to point to the relevant pages in the report. Abmayer (talk) 12:59, 6 December 2015 (UTC)