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Reaktie van Broderick

op kritiek van

van der Meer/Lloyd

op nieuwe ME-kriteria






In de Journal of Internal Medicine reageert Broderick (namens mede-auteurs) op

kritiek van van der Meer/Lloyd op de recente internationale konsensus-kriteria voor ME


Kort door de bocht, stellen van der Meer en Lloyd

  • dat het zinvoller is alle vormen van "vermoeidheid" als geheel te bestuderen
  • en dat het dus niet zinvol is de groep CVS-patiënten op te splitsen,

  • dat "vermoeidheid" in essentie hetzelfde is als "post-exertional malaise",
  • dat er drie groepen betrokken zijn die de zaak te simplistisch benaderen, namelijk mensen die beweren dat ME/CVS niet bestaat, mensen die beweren dat ME/CVS
  • een psychologische aandoening is en "aktivisten" (artsen, onderzoekers en patiënten),

  • dat zij zelf tot een vierde groep behoren: mensen die gemotiveerd zijn om
  • systematisch en onbevooroordeeld de biologische basis van "CVS" te achterhalen,

  • dat de naam ME niet juist is, omdat inflammatie niet overtuigen aangetoond is,
  • dat de auteurs van de konsensus-kriteria zich bezondigen aan pseudowetenschap,
  • omdat alle biologische afwijkingen "weerlegd" zijn en die studies niet vermeld worden.


Broderick stelt daarentegen

  • dat inflammatie ("ontsteking"), inclusief inflammatie van het zenuwstelsel, en andere immunologische en immunologische afwijkingen niet langer meer ontkend kan worden,
  • dat onderzoek naar "CVS" (Fukuda, Reeves, en Oxford-kriteria) weinig zal opleveren,
  • dat het zaak is mensen met immunologische-klachten-na-inspanning apart te bestuderen,
  • dat ME door we WHO als neurologische ziekte aangemerkt wordt (G93.3) en
  • dat andere vormen van chronische vermoeidheid niet onder die kategorie vallen.





Response to 'A controversial consensus'; By the International Consensus Panel

J Intern Med. 2012 Feb;271(2):213-7.

doi: 10.1111/j.1365-2796.2011.02499.x.

Broderick G.


PMID: 2221127




The cardinal symptom of ME is a pathological low level of threshold of fatigability that is characterized by a specific pattern of inability to produce sufficient energy on demand associated with measurable, objective, adverse responses to exercise.


This is a refinement of the much more inclusive criteria of fatigue that goes by the label of CFS and may or may not include ME. The panel did not intend to dismiss the broader range of components involved in fatiguing illnesses but instead focused on a patient population best described as having pathophysiological abnormalities that arise in response to exertion.




We believe that a prime cause of inconsistent and confusing research findings in this heterogeneous patient population has been the use of overly inclusive criteria for CFS such as the Oxford [4] and Reeves criteria [5]




However, ME is classified as a neurological disease, ICD G93.3. The WHO stipulates that the same condition cannot be classified under more than one rubric because individual categories and subcategories must remain mutually exclusive by definition. Therefore, ME (ICD G93.3) must be removed and kept separate from the overly inclusive criteria for chronic fatigue and malaise (ICD R53), which actually states that G93.3 is an exclusion of R53.




If the same symptoms consistently flare in response to exertion, they are more likely to share a common cause. For example, if a patient consistently experiences flu-like symptoms, sore throat and tender lymph nodes in response to exertion, it suggests that immune activation is a component of their underlying pathophysiology, which then can be studied scientifically.




Although the name 'myalgic encephalomyelitis' may not be perfect, it is the most accurate and appropriate name available and indicates underlying pathophysiology. Obviously, the ethical implications and medical risks prevent brain and spinal biopsies, thus limiting direct evidence.


However, spinal autopsies have identified neuroinflammation of the dorsal root ganglia (Chauduri A. Royal Society of Medicine Meeting 2009). There is simply too much evidence of pathophysiologic neurological and immune dysregulation, immune activation and an imbalance between inflammatory and anti-inflammatory mediators to be ignored [32–56].








A controversial consensus - Comment on article by Broderick et al

J Intern Med. 2012 Jan;271(1):29-31.

doi: 10.1111/j.1365-2796.2011.02468.x.

van der Meer JW, Lloyd AR.


PMID: 21988219





It cannot be denied CFS/ME is a controversial condition. The controversy – sometimes deteriorating into overt dispute – is between those that believe that it is a non-existent illness ('maladie imaginaire'); those that feel it is a psychiatric disorder; and the activists (comprising patients, doctors and even some scientists) who are convinced of a somatic disease – all are unfortunately simplistic perspectives on a complex disorder.


Separately, there are clinicians and scientists with an open mind, who recognize the disability associated with this enigmatic clinical illness, and who seek to engage scientifically in the challenge of defining the pathophysiology, and are therefore motivated to elucidate the biological basis of CFS in a systematic and unbiased fashion.




Although it is a widely held view that 'a better name is needed' [27], it is unfortunate that the authors propose to revert to the term 'myalgic encephalomyelitis' (ME), abolishing CFS. By doing this, they ignore the fact that inflammation (-itis) has not convincingly been demonstrated in any organ [28].




The literature cited in the paper is heavily biased towards positive findings (but sadly omitting the numerous failed replication studies), thereby creating a pseudo-science of the pathophysiology.




Another major problem with the proposed criteria is the suggestive and misleading phrasing: when describing the criteria that assess fatigue, the label becomes 'post exertional neuroimmune exhaustion'. Where is the Level 1 evidence for the 'neuro' and for the 'immune'? The same holds for 'neurological impairments' – all the listed items are subjective, none validated by objective abnormalities – for example, 'muscle weakness' and 'ataxia', which imply a demonstrable neurological deficit when one is present.




Under the auspices of the CDC-convened international expert group, we previously demonstrated that chronic fatigue states – regardless of exactly how they are defined, share a common and relatively stereotyped set of symptom domains which can be readily identified in the community, at all levels of health care, and across cultures [24].