Dr. Anthony L. Komaroff is the Steven P. Simcox/Patrick A. Clifford/James H. Higby Professor of Medicine at Harvard Medical School, Senior Physician at Brigham and Women's Hospital in Boston, and Editor-in-Chief of Harvard Health Publications. He was Director of the Division of General Medicine and Primary Care at Brigham and Women's Hospital for 15 years and is the Founding Editor of Journal Watch
, a summary medical information newsletter for physicians published by the Massachusetts Medical Society/New England Journal of Medicine
Here, Dr. Komaroff gives a wrap-up presentation of the major research presented at the 2014 IACFS/ME conference held in San Francisco, March 20-23.
Editor’s comment: Notably absent from this summary was any mention of Dr. Paul Cheney’s work on cardiac abnormalities in ME/CFS patients. Dr. Cheney, unfortunately, did not chair any of the sessions, but he did make an impressive poster presentation. Considering the fact that heart attacks strike ME/CFS patients 20 years earlier than the general population (Jason, 2006) and that exercise intolerance is the hallmark symptom of ME/CFS, Dr. Cheney’s work deserved to be acknowledged.
Talk 35 minutes, Q&A 17 minutes
Fred Friedberg, Ph.D., President of IACFS/ME
This is our Grand Finale, and it is tradition to ask Dr. Komaroff to provide a wrap-up summary, which is the best part of the meeting because with all his experience in dealing with Chronic Fatigue Syndrome in both clinical and research practice, his mind is like a steel trap, and nothing escapes it. It also has the ability to filter chaff from wheat, and therefore, he has the uncanny ability, the unique ability, to be able to distill down to its essence what is important and significant in these meetings. And once again, he has kindly agreed to offer his view of this meeting, and we are very grateful for his willingness and his ability to do this, and so I will thank him publicly for doing so, and without further ado, ask him to begin offering his wisdom to us.
Anthony L. Komaroff, M.D.
I will try to distill down to some simple slides the data and conclusions from the data that during this meeting impressed me the most. This is one person’s view of the highlights of the meeting. Inevitably, there will be very good work that I don’t mention. I really tried to find themes that spanned one presentation to the next. And that influenced heavily my choice of highlights.
SLIDE 1 – The Questions Addressed By Many of the Presentations (2:57)
I begin with the questions addressed by many of the presentations. Even though the work they were doing was entirely different, the general questions addressed were:
: In an illness defined exclusively by subjective symptoms, is there evidence of objective underlying biological abnormalities?
: Could those biological abnormalities theoretically explain the symptoms?
: Do the abnormalities in fact correlate with the symptoms? We’ll come back to those themes repeatedly.
SLIDE 2: Huge New CFS Databases and Biosample Banks (3:48)
One of the highlights of the meeting, to me, was not the result of any particular study, but the evidence that we now have huge Chronic Fatigue Syndrome databases and biosample banks. There is the longstanding work by Dr. Klimas and Fletcher now at Nova Southeastern University and the University of Miami and the Miami VA. You have at this meeting for the first time the presentation of the new very large effort at Stanford Medical School to build a database of clinical information and laboratory samples. We heard about the results of the Chronic Fatigue Initiative, a charitably-funded enterprise that created a large multicenter databank and biobank. We didn’t hear about, but there also exists as the result of a large NIH multicenter trial that was headquartered at Columbia by Drs. Lipkin and Hornig, which has another multicenter database with clinical information and biosamples. And then finally, we heard about the U.K. ME/CFS Biobank that is being developed.
SLIDE 3: Immunology Overview 1 (6:17)
Immunology was the first theme in the program on Friday, and the highlights of that to me were the CFS study (Chronic Fatigue Initiative Study) which found elevated levels of allergy-associated cytokines and chemokines and other pro-inflammatory cytokines and chemokines in patients who had been ill for less than 3 years in comparison to those who had been ill for greater than 3 years. It validated a sense by the study and its design that most of the biological action that you’re going to be able to detect is more likely to be there in the earlier stages of the illness than the later stages.
SLIDE 4: Stanford Inflammation Studies (6:32)
The second point, coming from the Stanford Studies was the ability of multiple inflammation-associated molecules—not all cytokines—even fat cell produced hormones, adipokines, to separate CFS cases from healthy controls.
Specifically, the Stanford studies that we heard about on the first day included nearly 200 CFS patients compared with nearly 400 age- and sex-matched controls, in each of whom levels of 51 different inflammation-associated molecules (cytokine family/chemokines and hormones) were measured. To my knowledge, with the possible exception of the CFS study, a study of that size simultaneously assessing that many different molecules is unparalleled, not only in the CFS field, but in many fields.
15 of the 51 molecules that they focused on either distinguished cases from controls or correlated with symptom severity or both.
SLIDE 5: Correlation of Inflammation-Related Molecule Levels With Illness Severity (7:47)
Here’s a sample from one of Dr. Montoya’s slides. You can’t see it very well, but this is a group of, I think, 14 or 15 different cytokines that plots severity of symptoms against the level of the cytokine. And I think you can see that for most all of these cytokines, as the symptoms became more severe, the level of the molecule was higher. There is a linear correlation between the molecule and the symptom. It doesn’t mean that the molecule is causing the symptom, but it could mean that.
SLIDE 6: Cytokine network (8:41)
Another way—and this also doesn’t project well—Jarred Younger and Dr. Montoya’s Center did a study looked for associations between the various cytokines. The startling result was the primacy of Leptin. Leptin is a hormone discovered about 1994 that is made by fat cells and that diminishes appetite and has a powerful role in weight regulation and appetite control in humans and animals. These elevated levels of leptin in CFS patients were correlated with the severity of the symptoms, particularly fatigue. That that molecule should be so closely tied to immune system molecules, cytokines, was striking, and that it should so predominantly correlate with the levels of fatigue in the CFS patients was a novel insight, the meaning of which I’m sure many groups will be pursuing.
SLIDE 7: Immunology Overview 2 (9:41)
Another highlight of the Stanford Study, also found by the CFI study that Dr. Hornig reported on, is elevated levels of Interleukin 17. This is the prime mover of the so-called Th-17 immune cell that has been very strongly linked to many human autoimmune disease. More precisely, an elevated level of IL-17 or the Th-17 cell, compared with what are called T-regulatory cells makes the risk of many autoimmune diseases worse, and suggests that autoimmunity may be playing a role in CFS.
Significant decreases were reported in several micro-RNA’s that control the production of pro-inflammatory cytokines. That is, the decrease in the micro-RNA would tend to increase the production of pro-inflammatory cytokines, which is what was found by the study. So it’s internal, biological confirmation of what you would expect to see if these findings are really valid.
And then finally, there were, to me, striking results about one particular cytokine, interferon-gamma.
I want to take a brief side tour into a statistical term, Odds Ratio, for those who are not familiar with it.
SLIDE 8: Odds Ratios (11:44)
An Odds Ratio compares the frequency of a finding, any finding, in one group (like people with CFS) versus the frequency of that finding in a comparison group (like healthy controls). If you have an odds ratio of 1.0, it means there is no difference in frequency between the two groups that you’re comparing. If the confidence interval spans 1.0, it means the difference is not statistically significant. Most of the odds ratios that you see reported in the literature on most conditions and most of the odds ratios you saw at this meeting fall into the range of between 1 and 5. It’s not very common to see odds ratios in large studies that go above 5. It means there is a five-fold greater chance of a finding in one group compared with the other.
SLIDE 9: Interferon-Gamma and CFS (12:54)
We had two striking odds ratios from Dr. Hornig’s group on Interferon-Gamma. In the CFI Study (Chronic Fatigue Initiative Study) 200 cases compared those who were ill for less than 3 years with those who were ill greater than 3 years. The odds ratio of Interferon-Gamma was 117, with the upper confidence interval being one thousand seventy-two. I’ve never seen an odds ratio like that. I’ve never seen an association that so strongly discriminates one group from another. That same molecule, interferon-gamma, was found to correlate with cognitive impairment, with an odds ratio of 67. This is a striking statement about this molecule and its possible role in this illness. Interferon-gamma is thought to be commonly released by viral infection or infection within intracellular bacteria. So it suggests, but by no means proves, that in CFS there may be an underlying infectious agent.
SLIDE 10: Basic Biology (15:08)
The telomeres, the ends of the chromosomes, are shorter in patients with CFS than in matched healthy control subjects
Telomere length is a marker for cellular aging: shorter telomeres denote cells aging more rapidly
Shorter telomeres also predict an increased vulnerability to a variety of “diseases of aging”
One demonstrated association with shorter telomeres is perceive life stress
Telomeres are shorter in patients with CFS vs healthy
We heard another interesting finding at the meeting was about telomeres. Telomeres are the ends of the chromosomes where they all come together at the opposite ends of the chromosomes. Over the last 30 years it has become clear that those telomeres are not just structural elements, that their lengths affect the viability of the cell. With every cell division, the telomere shrinks a little bit. Therefore, short telomeres mean this is a cell that has divided many times and is relatively older. When telomeres get to be short enough, all of a sudden, the cell dies.
Short telomeres are a marker for cellular age. And short telomeres are increasingly being shown to predict an increased vulnerability to a variety of diseases of aging, including atherosclerosis, neurodegenerative diseases, and several malignancies. One demonstrated association with shorter telomeres is perceived life stress. That work was done here in San Francisco at UCSF by Elizabeth Blackburn, who won the Nobel Prize four years ago for her work on telomeres. She showed that when people are under stress, were likely to have shorter telomeres. (The group she first studied was parents caring for sick kids.) Dr. Rajeevan from CDC showed us good data that telomeres are shorter in patients with CFS. This is by no means a finding unique to CFS, but it’s a finding that suggests that there is an underlying biological process that is making patients with CFS age a little faster.
SLIDE 11: Virology/Infectious Agents (16:48)
Virology and Infectious Agents was the next general section of the meeting. The Chronic Fatigue Initiative Study reported the results of a really intensive molecular screen for infectious agents. The first report was about agents in serum. They found, basically, no evidence of microorganisms present in serum. The questions to be addressed in the future are: what about in circulating white blood cells, the cells themselves, not the serum around them? And what about in other organs, including other compartments, particularly the brain and gut, the microbiome? Those are studies for a future time, several of which are under way.
Dr. Chia reported again at this meeting the latest summary of data from a remarkable report and a remarkable amount of work: Enterovirus Antigen and nucleic acid found in biopsy samples from stomach in cases and control subjects. He found very marked differences in the frequency of both antigen and nucleic acid in CFS patients compared with controls. He also reported that when you took biopsy specimens from CFS patients, and injected them into mice, there was evidence of enteroviral infection in the mice. This indicates that there is an infectious agent in the patients.
These results are very impressive, but it’s also depressing to see that, to my knowledge, no academic enterovirologists have sought to try to reproduce this, or to take the samples that already have been collected at enormous effort by Dr. Chia and test them themselves to see if they get the same results that Dr. Chia does. It’s a great shame and I hope it changes.
SLIDE 12: Public Health/Epidemiology (20:46)
The Canadian Community Health Survey was massaged to try to come to an estimate of the number of Canadians that have CFS, and estimated about one percent (411,500). That’s about 2 to 5 times higher than in the United States. It may be just because these data come from a survey and patients weren’t then subjected to physical exam and deeper interrogation to see if they might have other conditions that cause fatigue.
The CFI Epidemiology Study surveyed nearly a thousand patients who had been from multiple centers and ascertained that about a third had experienced at least one remission during what typically was a 15-year history of illness and that the remissions had lasted on average about a year, but in most people, unfortunately, the remission had not persisted. It is the latest study of prognosis of this illness in a long-term data base.
The CFI Epi Study also reported that rest, exercise and diet were the interventions that most CFS patients have found helpful in comparison to standard pharmacological therapy or alternative and complementary treatments.
The CFI Study finally revealed that CFS patients were much more likely to report many comorbid illnesses than were control subjects.
SLIDE 13: Case Definition (21:26)
Case definitions need to be precise: the way in which each component is defined needs to be specified—e.g., how severe is “severe”
Empirically-derived case definitions are superior to consensus-derived case definitions: Better at defining subgroups
Better at predicting an endpoint—e.g., prognosis, a laboratory finding thought to define the pathology of the illness
Lenny Jason magnificently led the discussion of what you want in a case definition. The points he made were that case definitions, if they’re really going to do the job you want them to do, need to be precise. You don’t want to just list a group of symptoms or physical exam findings, you want to tell the person who might use that case definition how you actually define that symptom. When is the severity of that symptom high enough that you want to check the box?
Empirically-derived case definitions, he argued, are superior to consensus-derived case definitions, such as most that exist today, because they become better at defining subgroups. If you just collect a lot of data very rigorously and use statistical techniques to look for subgroups, the data tell you which symptoms correlate in most patients. More needs to be done in defining subgroups because I think most of us believe CFS is, if not a group of different but similar diseases, it is a disease with a bunch of subgroups that may, in fact, respond to different treatments.
And finally, empirically-derived case definitions are going to prove to be better at what you want a case definition to do, which is to predict some endpoint, such as a prognosis or a laboratory finding that’s thought to define the pathology of the illness.
SLIDE 14: Exercise “Provocation” Studies (23:35)
A stressor that makes a patient feel worse should also bring out the underlying pathology—and a double-dose of a stressor should do so even more
Though on a single exercise study CFS patients did not consistently perform below normal, a Second test the next day found abnormal VO2-max in 95% of patients
Same finding for pulmonary ventilation
This degradation of performance not seen in healthy, nor in people with heart/lung disease
Low peak oxygen extraction relative to increase in cardiac output, implying a metabolic defect (possibly downregulation of carbohydrate metabolism)
The next session was really a session about exercise studies. The main concept behind these studies was that if patients tell you that a particular stressor makes them feel worse, then the time to study is when they’ve been subjected to that stressor and are likely feeling worse. And, in fact, a double dose of that stressor should bring out the underlying pathology even more.
What we heard from several groups is that on a single exercise study CFS patients did not consistently perform below the levels of healthy controls, but when those patients were exercised 24 hours later again, you saw all sorts of abnormalities popping out. You did not see a degradation in performance on the second test in healthy control subjects, nor did you see it in people with heart disease and lung disease, who are the main people who get this kind of exercise study. This doesn’t mean that this degradation on the second day is unique to CFS, but it says that in their long experience as exercise physiologists they haven’t seen it before. And that’s probably telling us something about this illness.
Finally, we heard a report that low peak oxygen extraction relative to an increase in cardiac output occurs in some patients, implying a metabolic defect, possibly a downregulation of carbohydrate metabolism.
SLIDE 15: Pediatric CFS (25:54)
Surprisingly high prevalence of delayed milk protein sensitivity in kids with CFS
Combination of widely available/inexpensive laboratory tests may predict which people with mono go on to post-mono CFS
Depression was found only in 25% of pediatric CFS patients—even after the onset of the illness
There was a surprisingly high prevalence of unrecognized, delayed milk protein sensitivity in kids with CFS. By changing dietary patterns, you might be able to relieve some of the suffering of kids with CFS.
Second, a paper talked about a combination of widely available, inexpensive laboratory tests that appeared to predict which young adults and teenagers with mono would go on to develop post-mono CFS. We know from 15 years of research that there is a post-mono CFS, and several fancy laboratory studies seem to predict who’s going to go on to get post-mono CFS. But those studies can’t really be done reliably in most practices. The types of laboratory tests that were reported here are available to every laboratory and are very inexpensive, and this may prove to be a useful finding for intervening in some way to prevent post-mono CFS.
Finally, the last report in the pediatric session was that when they surveyed kids with CFS for depression, they found evidence of a concurrent depression in only about 25 percent of the kids, even in the months and years after they became ill with CFS. In teenagers particularly, I believe the background prevalence of depression is around 15 to 20 percent. So this is marginally higher, as you might expect when you’re suddenly hobbled with a debilitating illness, but it is only in a minority of the patients.
SLIDE 16: Brain Research (27:58)
We heard from the Zinns at Stanford about quantified EEG studies, brain wave studies, that demonstrated a remarkable ability to distinguish CFS patients from healthy control subjects. And I’ll cite that data in a minute. And we heard from the Osaka and Kobe studies of an activation of key brain immune cells—microglia and astrocytes—using PET scanning that say something about the underlying biology of the illness.
SLIDE 17: qEEG Changes In CFS (28:33)
One of the Stanford studies we heard about this morning involved brain wave comparisons between 50 CFS patients and 50 matched controls. Peak alpha wave frequency was significantly reduced over most of the cerebral cortex in patients with CFS. Delta wave frequency was increased and beta wave activity was also reduced.
This was particularly true in the frontal lobe and the limbic areas of the brain, and both abnormalities not only were present and clearly distinguished CFS patients from healthy controls, but the degree of the electroencephalographic abnormality correlated linearly with the degree of the symptom, whether it was fatigue or pain.
These brain wave abnormalities were thought by the Zinns to indicate likely disruptions of information transfer across cortical networks and inhibition of ascending arousal systems. They are the sorts of things that you see in a whole host of well-documented neurologic diseases and you don’t see in healthy people.
SLIDE 18: Past Osaka/Kobe Japan PET Scan Studies (30:12)
Reduced cortical blood flow
Reduced serotonin transporter
Increased dopamine biosynthesis
The PET scans that have been done by the Japanese groups in the past have demonstrated reduced cortical blood flow, reduced glutamate (an important nerve transmitter), reduced serotonin transporter, and increased dopamine biosynthesis.
SLIDE 19: Neuroinflammation by PET Scan (30:52)
At this meeting, the Osaka/Kobe Japan groups used PET scanning for a new purpose. CFS might reflect an ongoing activation of immune cells in the brain, not in the periphery. If you could find evidence of a chronic immune activation state in the brain, then all of the cytokines that are elaborated as part of that chronic immune activation could easily explain many of the symptoms of CFS.
But how do you measure immune system activation inside the intact brain of a human being without some invasive approach?
Their imaging technology included a ligand for a particular protein that is thought to be specific to the activation of the immune system cells—the microglial cells and astrocytes—and it showed that in a small study (9 patients, 10 controls) there clearly was increased signaling evidence of immune activation in these cells in multiple areas of the brain, areas that incidentally have also been found to be abnormal in many other kinds of imaging studies.
The intensity of the signal correlated with cognitive impairment. That is, they did not just find an abnormality but demonstrated that it correlated with the degree of important symptoms.
SLIDE 20: The Questions Addressed by Many of the Presentations (32:31)
Many of the presentations today asked the question: In an illness that’s defined entirely subjective symptoms, is there evidence of underlying biological abnormalities? I think the evidence, clearly, is yes.
Could those biological abnormalities theoretically explain the symptoms? You’ve heard multiple investigators say yes, absolutely they could, from what we know about those abnormalities in other conditions and diseases.
And then, finally, do the abnormalities that theoretically could correlate with the symptoms actually correlate with the symptoms in patients who are reporting their symptoms at the time they’re being imaged or studied? And the answer was repeatedly, yes.
SLIDE 21: In Summary (33:16)
In summary, I would conclude that over the last three days, and the science that’s been reported over the last twenty years, shows repeatedly that when patients with CFS are compared to various comparison groups—healthy subjects and in many cases, other fatiguing diseases – what you find is robust evidence for an underlying biological process that involves the brain, autonomic nervous system, immune system, energy metabolism and, although we didn’t hear a lot about it at this meeting, oxidative and nitrosative stress.
This illness is not simply the expression of somatic symptoms by people with a primary psychological disorder. It was a fair question thirty years ago to ask whether people with these symptoms might not just be expressing psychiatric stress, amplifying normal body sensations, or even fabricating for secondary gain—was a fair question thirty years ago, but today it’s no longer a fair question.
[Editor’s comment: Given the fact that the 1984 Incline Village epidemic affected hundreds of people, the question of whether people were fabricating the illness 30 years ago was absolutely not fair. Nor was it fair 59 years ago after the Royal Free outbreak. There is no evidence of any kind that supports the idea that large numbers of people fabricate disabling illnesses over long periods of time.
Nancy Klimas, M.D
.: Tony, do you think we are at the point where we can use biologic markers for this disease clinically?
: Well, I don’t think we have evidence yet that any of these biologic markers is sufficiently sensitive or specific to constitute a diagnostic test. Several are close. And one of those EEG figures showed nearly a perfect separation between cases and controls. So, maybe that day is coming, but I’m not sure that we have yet something we can call a diagnostic test.
: How about clinically to monitor for… pick a drug. For managing and following and therapy decision making, should we up the ante and start ordering anything else?
: I think , for example, the finding that dopamine is downregulated could lead to a trial, but it would have to be a randomized trial of interventions that ramp up dopamine production. I think that where you find a result that has a therapeutic implication, the drug ought to be tested in a randomized trial. I’m less comfortable with saying a dopaminergic agent should be used in an uncontrolled setting to treat patients, but I would hope it would lead to controlled studies.
: Given the fact that the Japanese group found neural inflammation in the hippocampus and maybe the hypothalamus and the pons, which is anatomically part of the spinal cord, isn’t that encephalomyelitis?
: Yes. If it were confirmed by multiple other investigators it would indicate there is low-grade chronic encephalitis in these patients. The image we as clinicians have of encephalitis as an acute and often dramatic clinical presentation that can even be fatal may have blinded us to the possibility that there may be an entity of long-lasting, cyclic, chronic, neuroinflammation that is underlying the symptoms of this illness. It is entirely plausible. These data are consistent with it. But I would feel more strongly if other labs using the same technology came to the same result.
: This question may be more for Dr. Klimas. In terms of the cytokine changes that we’re seeing consistently over various labs all over the world as well as NK cell function, how can we use biologics in terms of the Norwegian study with Rituximab to make sense of any improvement in certain patients?
: Immune-based biomarkers are reasonable places to define subgroups, particularly as we move towards therapeutics that are very specific. That way we are much more likely to have the level of efficacy that catches everyone’s attention. We have reliable ways to confirm our observation that TNF is elevated, so we can use a TNF.
: I’m an advocate, so this is an advocacy question. Thank you, Dr. Komaroff for your summary. It was great. Coming to these conferences year after year, it’s so promising and we always end on the same note, that there’s so many biological abnormalities, and yet one can’t seem to declare that we have biomarkers, and my question is, it’s sort of a chicken and the egg question. Until we accept a universal case definition for this disease, that may always be the case. We might not have as many subgroups for this disease as we think because we’re not replicating science, and we’ll never find targeted drugs. We all need to admit that we need to adopt a single case definition; for example, Canadian Consensus Criteria would be one such, so I would like to ask you to address that and also to address the fact that, you’re so wonderful in all your summaries of biological abnormalities on the CDC website, here and everything else, and advocates were astonished two days ago with your interview that appeared in the Monterey Herald
that said wonderful things about the biological abnormalities, but it ended with saying that CBT and GET are really good treatments, so if you could address both of those?
: I don’t want to get dragged into a discussion of the role of CBT, because I know it’s a polarized issue. It wasn’t discussed at this conference, and I don’t want to… I’ll be happy to talk with you individually about it.
In terms of whether all investigators should use a common case definition, yes, that would be the ideal. And I think the problem is that not all investigators agree on what’s the best and easiest to implement case definition. Part of the problem with choosing any one is that if there’s a lot of literature already that uses another case definition besides the one that you regard as currently best, it’ll be hard to compare the results of any studies going forward with the published research that already exists. I don’t think there’s a good answer to that question. And, if there is, I don’t have it.
: Could I just say more about potential clinical trials? We had a poster up which presented an approach that I think would be quite useful in facilitating this process. As we all know, we do not have an animal model for ME/CFS. But we can take peripheral blood mononuclear cells, which we have in great supply in a number of big biobanks, and we can test at least immunologic markers as potential targets in that system. And we had whole serum which we previously reported that interleukin 15 is increased in ME/CFS. And we also know that it is a potent stimulus of natural killer cells which are low. And we can show in the test tube, we can expose those PBMCs to interleukin 15 and increase their activity by about a hundred and fifty percent. So, in this time frame, it could be used for a lot of immunologic markers. It can be used both in inhibitors of cytokines and cytokines depending on what defect we’re interested in addressing. We’ve had a little bit of trouble getting this concept funded, but I’m hopeful still.
: I very much agree. Where you have a signal that says if we boosted this or if we suppressed it, we might see improved symptoms, we should do the studies in a controlled trial. Is IL-15 synthetic IL-15 available for human use?
: Yes. Dr. Waldmann at NIH discovered this cytokine and he actually has clinical trials in progress using it in cancer.
: I have read numbers of papers where people, especially in China, have tried to construct animal models in which they make mice swim back and forth, back and forth , back and forth, about a million laps, and exhaust them that way and this they called a CFS model. And it has always occurred to me, that giving the mice a good hit of interferon on a regular basis could possibly be one way to construct an animal model, and I’m really asking that question. Is that possible?
: Animal models exist and we certainly can use them.
: I want to thank Tony for his wrapup and concluding this meeting with an elegant presentation.
On behalf of the IACFSME, I want to thank each and every one of you for attending our meeting, and in that way supporting us, and demonstrating an interest in this illness. For those of you who are healthcare providers, I want to thank you for providing care for our patients even though they may disbelieved by the mainstream and not believed by many. Obviously, you do. And for that I wish to thank you, not only on behalf of the organization but also personally on behalf of being a parent of a child who has the illness. So thank you very much.