UK Genome Wide Association Study (GWAS) project - draft website goes live, feedback sought on recruitment plan, and updates

[Barry]

I'm not sure about that. Doesn't that risk including people who had something else which was misdiagnosed as ME?

My response was assuming the diagnostic criteria would still be validly applied, though I agree there might be problems with achieving that, and if so that would indeed be very problematic.

The trouble is, there likely are people who have genuinely suffered from ME/CFS and for whatever reason have genuinely recovered, or mostly so. The information lurking within data from those fairly unique patients could be important to understanding the disease; would their genetic makeup show something different from other pwME? As yet we have no way of knowing if people who recover from ME/CFS do so due to genetic and/or non-genetic reasons. But of course you are right, accurate diagnosis would be crucial, as for all other participants, else might see something that looked significant but was not.

 

[Andy]

Website has been through another round of formatting edits, https://mebiomed.org.uk/

Many thanks to all those who have made suggestions on how it could be improved.

 

[Andy]

Much has been said recently about questionnaires. My personal opinion is that much of what is being talked about goes beyond the scope of this GWAS, however I'd like to highlight

When people sign up to this study, we will ask them if they are willing to be contacted about taking part (directly, or by agreeing to share samples and data from this study) in new studies, either related to this one or unrelated. This will make it much easier for researchers to recruit participants for studies, speeding up the pace of research.

from https://mebiomed.org.uk/faqs/

So I will be looking for us to use the fewest questionnaires required for the GWAS to be successful but with the above action we will be making it easier for anybody who wishes to follow-on with any future study, whether that be questionnaire based or not.

 

[MerryB]

Yep, I think very definitely from my own little focus group investigation

Did they say why?

 

[MerryB]

So I will be looking for us to use the fewest questionnaires required for the GWAS to be successful but with the above action we will be making it easier for anybody who wishes to follow-on with any future study, whether that be questionnaire based or not.

Thank you Andy. Perhaps I'm just being over-anxious about this, but is the association that the GWAS will be looking for against the genes: 'having ME vs not having ME'?

Or will it go as far as sub-phenotyping ME cases?

One big reason I suggested additional questionnaires was because ME is heterogeneous, there is a chance that it is not one genotype but several different ones, each comprised of a different cluster of SNPs?

And that lumping them all together in one 'having ME vs not having ME' phenotype analysis might not turn up (or might dilute) any statistical significance?

If this were to be the case, it might be necessary to sub-phenotype the ME cases to see whether there was statistical significance in clusters of SNPs associated with sub-phenotypes?

The only practical way to sub-phenotype ME cases on this scale, with the resources available to the GWAS, would be by questionnaires to identify symptom clusters, disease/health history, onset type, environmental exposures, etc.

I am basing this concern on the oft-cited concept that ME might not be one homogeneous disease with one genotype, but might be several different diseases with very similar presentations. In my mind it would be valuable to have data that can be used to try to sub-phenotype ME cases to see whether this turns out more statistically significant results, in case the whole-cohort 'having ME vs not having ME' doesn't identify statistically significant associations.

Because in the latter scenario it would be a lot of work for nothing, whereas if there was data to draw on to try sub-typing patients this could increase the likelihood of getting meaningful results, especially since we know ME is complex and heterogeneous.

Does this make sense?

 

[Invisible Woman]

@MerryB, it seems to me you are assuming that these questionnaires will be able to accurately identify sub-types. Why?

Most of the questionnaires were designed for other patient groups and may erroneously cause a different diagnosis to ME, or erroneously diagnose co morbities. So I, personally, doubt they'll accurately tell us much about sub types. If the questionnaires are optional then you may get self selecting sub types filling them in - that could skew your data.

Many of us have had additional suffering inflicted on us thanks to the use of these very questionnaires.

The GWAS is a starting point. It may be that it is immediately clear which is the ME patient and which is not and that opens up one line of questioning. If it is unclear than that will open up another. Maybe the GWAS will even help produce a fit for purpose questionnaire.

Why give yourself the extra financial burden when research funds are already scarce? Why give yourself the extra workload when the data itself may throw up other far more pertinent lines of enquiry?

 

[Kitty]

there is a chance that it is not one genotype but several different ones, each comprised of a different cluster of SNPs?

I do see your point, but if this phenomenon exists, won't it need to be picked out of the GWAS statistically rather than from participants' symptoms?

If there aren't any visible differences at all between ME patients and controls, there's no point proceeding any further with GWAS research. It's unlikely that nothing would show up – I'd expect it to be more a question of whether any differences are significant, and which of them might be meaningful – but to answer the research question, the evidence surely need to come from the genetic data itself.

I think tying any genetic differences to symptoms, severity, and onset type is probably much further down the line. It may not be possible (or even necessary) to work it out objectively.

 

[JemPD]

Sorry I haven't the energy to quote everyone, but just wanted to say that although I can see the point of wanting to subtype.... I agree with all the arguments against having any additional questionnaires included. At this point it should be only what is necessary for the GWAS.

 

[JemPD]

@Andy apologies if this has been already pointed out but the FAQs have a typo

What is a genome-wide association study?

A genome-wide association study (GWAS) is a very large genetic study that seeks to uncover some of the biological roots of ME/CFS. By probing small DNA differences among people, a GWAS can help to pinpoint the genetic causes of disease and then can help to guide drug development. This design has previously provided helpful in identifying genes together with molecular and cellular pathways to contribute to disease risk. Read more about the science of GWAS.

shouldn't that be either 'previously proved helpful in identifying', or 'previously provided helpful information (or some other word) in'

A big thank you for everyone's hard work on the study & on the site too.

 

[JemPD]

Bit off-topic but my favorite marketing approach would be a "Take on ME" campaign, using the song of the same title by A-ha

I love that idea

ETA Although maybe not.
it could too easily be twisted?... (look away now if you easily upset by nasty comments about sufferers)
quite a few deriders love to use the fact that M.E. spells 'me', to suggest we are selfish/lazy etc...
"it's the ME(me) syndrome", "It's all about ME ME ME", "sufferers need to look at the name of their condition for the cause/cure of their condition"

etc etc etc blah blah blah I'm sure you've heard them all too.

 

[wigglethemouse]

So I will be looking for us to use the fewest questionnaires required for the GWAS to be successful but with the above action we will be making it easier for anybody who wishes to follow-on with any future study, whether that be questionnaire based or not.

Would a partnership with SolveME to use their registry for the purpose of registering for future other studies make more sense. That resolves the issue of who maintains the list long term, and who decides who has access to it. Those resources may not be available long term for the GWAS team (or would the Biobank maintain the list which may make more sense)?

 

[Invisible Woman]

Would a partnership with SolveME to use their registry for the purpose of registering for future other studies make more sense.

Would this involve signing up or committing to using their app? Some ME patients don't use smartphones. Others (like me) will not agree to downloading an app on their smartphones.

Edit- also re the app - I found keeping a diary for symptoms and activities a huge additional burden in the past. I also found it to be a wholly negative experience as it just focused my mind on ME all the time.

 

[Andy]

Thank you Andy. Perhaps I'm just being over-anxious about this, but is the association that the GWAS will be looking for against the genes: 'having ME vs not having ME'?

Or will it go as far as sub-phenotyping ME cases?

To respond I'll highlight information from the FAQ again.

Our goal is to identify causes of ME/CFS. For this we will first isolate and analyse your DNA from the saliva sample. We will then look at around a million common variants in DNA and see if any of the variants are more or less common in patients than seen in control individuals. Survey data such as age, type of onset and symptoms will be used to gain a better understanding of your background and illness and we will link this survey data to your genetic data.

We may also ask people if they are willing to provide us access to their electronic health record, with personal clinical information kept by their GPs. This would help us to get a more detailed understanding of your illness, progression and symptoms, but would be entirely optional and would not affect eligibility for the study.

 

[Andy]

Would a partnership with SolveME to use their registry for the purpose of registering for future other studies make more sense. That resolves the issue of who maintains the list long term, and who decides who has access to it. Those resources may not be available long term for the GWAS team (or would the Biobank maintain the list which may make more sense)?

We are exploring options.

 

[Andy]

Would this involve signing up or committing to using their app? Some ME patients don't use smartphones. Others (like me) will not agree to downloading an app on their smartphones.

Edit- also re the app - I found keeping a diary for symptoms and activities a huge additional burden in the past. I also found it to be a wholly negative experience as it just focused my mind on ME all the time.

While we are exploring what options are available to us, we are keeping in mind that the burden for participating in the study should be as light as is possible, in order to allow as many patients as possible to take part. Whatever platform we use in the end should make things as easy as possible, not add unnecessary tasks.

 

[Saz94]

I understand that the me/cfs biobank questionnaire is being used to check that participants have me/cfs?

When I did the biobank questionnaire last year, there was a question like "do you have fatigue that is not relieved by rest?" I think this is not a good question because when I was less severe, I could feel okay if I rested a LOT - I'm sure that is true for many people with "mild" or maybe even "moderate" ME? The issue was that the amount of rest needed in order to relieve my fatigue was excessive. And the amount of fatigue triggered by ordinary activities was excessive.

* * *

Also, I am wondering whether the biobank questionnaire will be able to differentiate people who have PEM from people who have post-exertional fatigue but not PEM? As I think we're all agreed that the latter shouldn't be included in an me/cfs study.

This needs to be made very clear in how the questions are asked, because a lot of people don't understand the difference between PEM and PEF and will say they have PEM when they don't really. (Especially since a lot of people in the UK have been diagnosed with ME/CFS purely because they have fatigue and the doctor didn't investigate much further.)

I even have trouble articulating what the difference is. For a lot of PWME, PEM involves additional symptoms / symptoms worsening, as well as fatigue. But mine often only consists of worse fatigue... So partly I'm not sure whether mine even counts as PEM? But if it does, then how do we articulate the difference between that and PEF? We can't just say that it's different in the amount of fatigue triggered, because people with other energy-sapping illnesses also experience PEF which is abnormal in intensity compared with a healthy person.

Perhaps 'recovery time' is a differentiator? But I'm not sure, because I read that people with untreated hypothyroidism can sometimes require several days to recover from physical exertion. I do wonder whether we PWME tend to underestimate the 'recovery time from activity' required by people who have other energy-affecting health conditions? Also, some people diagnosed with ME do seem to present with a PEM-like pattern that resolves after only a day or so?

I suspect the difference is this: if you are in PEM, and you continue to exert yourself without resting enough, then you can go on a huge downwards spiral and risk eventually ending up in a long-term state of extremely severe (think of the severity of e.g. Whitney Dafoe). For somebody experiencing PEF, this is not going to happen; continued exertion will just make them more tired, and their energy level will go back towards their 'normal' once they have rested plenty. Whereas if I overexert to the extent that it pushes me down to a worse level of ME severity (this does not happen every time, just with really bad or protracted overexertions); then once I've been at that worse severity for a few days, that becomes my new 'normal' and no amount of rest can get me back to what my 'normal' was before the overexertion.

It's really hard. I wonder if you can't properly understand the difference between PEM and PEF-with-a-different-health-condition unless you've experienced both yourself and know what the difference in feeling is. And it can be very hard to articulate how something feels... it is for me anyway.

You also want to include people who rarely get PEM because they manage to avoid overexertion.

 

[Kitty]

how do we articulate the difference between that [PEM] and PEF?

Does everyone get immune symptoms with PEM? I've always had this, but I don't know whether it's universal. If I've only exceeded my energy envelope by a bit, it's nothing more than slightly raised neck glands on waking, which go down again within half an hour.

Once you recognise it – rather than dismissing it as dehydration from mouth breathing, or something like that – it's unmistakable as an immune response. If it is universal, then questions would need to be carefully framed to describe it, as I'm sure some people with mild ME won't recognise it as a PEM symptom.

 

[Barry]

When I did the biobank questionnaire last year, there was a question like "do you have fatigue that is not relieved by rest?" I think this is not a good question because when I was less severe, I could feel okay if I rested a LOT. The issue was that the amount of rest needed in order to relieve my fatigue was excessive. And the amount of fatigue triggered by ordinary activities was excessive.

I fully agree. Questions like this are not at all suitable for diagnosing ME/CFS in my opinion; they are so very ambiguous it can be pot luck when answering a question that should not be asked in the first place. In my wife's case, yes there is some relief (what would be the point of resting otherwise!), but it is nothing like the relief if she were healthy, neither degree nor quality.

For a lot of PWME, PEM involves additional symptoms / symptoms worsening, as well as fatigue. But mine often only consists of worse fatigue... So partly I'm not sure whether mine even counts as PEM? But if it does, then how do we articulate the difference between that and PEF? We can't just say that it's different in the amount of fatigue triggered, because people with other energy-sapping illnesses also experience PEF which is abnormal in intensity compared with a healthy person.

You also want to include people who rarely get PEM because they manage to avoid overexertion.

Fully agree again. My wife seems to instinctively know how to pace herself well, so her PEM is typically about feeling shattered and not very well, and will be back to her norm next day. But if she gets it wrong, or circumstances overtake her, she ends up feeling bl**dy ill and way beyond shattered, and she will definitely not be OK by the next day.

As usual these questionnaires were originally designed by people who presumed to understand ME/CFS, and what questions to ask. But ME/CFS is unique in many ways, and needs its own very carefully thought out questionnaire.

Maybe diagnosis could itself be much better if a much improved questionnaire were designed. But an undertaking not to be underestimated, let alone then proving its validity.

 

[Saz94]

Does everyone get immune symptoms with PEM? I've always had this, but I don't know whether it's universal. If I've only exceeded my energy envelope by a bit, it's nothing more than slightly raised neck glands on waking, which go down again within half an hour.

Once you recognise it – rather than dismissing it as dehydration from mouth breathing, or something like that – it's unmistakable as an immune response. If it is universal, then questions would need to be carefully framed to describe it, as I'm sure some people with mild ME won't recognise it as a PEM symptom.

Many do get it, but a fair number don't. I ran a poll on this forum about PEM symptoms a few months or so ago.

 

[Kitty]

I ran a poll on this forum about PEM symptoms a few months or so ago.

Sorry, I'd forgotten all about that! Not having a great day today.