PACE Trial: letters and reply | Journal of Psychological Medicine ...

From the Journal of Psychological Medicine, August 2013.

CORRESPONDENCE

Editorial note

Unusually for Psychological Medicine, we publish below six letters concerning the paper by White et al (2013) on the PACE Trial. The UK Office of the Journal received 15 letters criticising aspects of this paper, but it seemed unlikely that all of these letters originated entirely independently since a number arrived on consecutive days and reiterated the same points. Nevertheless, in the spirit of scientific openness, we have published six of the letters which cover the main criticisms, and invited Professor White to reply to them.

References
White PD, Goldsmith K, Johnson AL, Chalder T, Sharpe M; PACE Trial Management Group (2013). Recovery from chronic fatigue syndrome after treatments given in the PACE trial. Psychological Medicine. Published online: 31 January 2013. doi:10.1017/S0033291713000020

ROBIN MURRAY
Joint Editor ??Psychological Medicine

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In their paper on recovery rates in the PACE trial, White et al. (2013) acknowledge that `objective measures of physical activity have been found previously to correlate poorly with self-reported out- comes. Yet, there is no attempt to utilize the Six Minute Walking Test results. The best results were a mean of 379 metres walked in the graded exercise therapy condition, a gain of 67 metres in 52 weeks, 35 metres more than the specialist medical care (SMC)-only group (White et al. 2011). The cognitive behaviour therapy group showed no improvement compared with the SMC group. The distance of 379 metres is exceeded by patients listed for lung transplantation (Kadikar et al. 1997) and by older patients with chronic heart failure (Lipkin at al. I986). Given the recognized problem with self-reported outcomes, reliance solely on such measures leaves open the question of the validity of the recovery criteria of PACE.

Declaration of Interest
None.

References
Kadikar A, Maurer J, Kesten S (1997). The Six-Minute Walk Test: a guide to assessment for lung transplantation. Journal of Heart and Lung Transplantation 16. 313-319.

Lipkin DP, Scriven A], Crake T, Poole-Wilson PA (I986). Six minute walking test for assessing exercise capacity in chronic heart failure. British Medical Journal 292. 653-655.

White PD, Goldsmith K, Johnson AL, Chalder T, Sharpe M; PACE Trial Management Group (2013). Recovery from chronic fatigue syndrome after treatments given in the PACE trial. Psychological Medicine ? Published online. 31 January 2013. doi:10.1017/S003329173000020

White PD, Goldsmith KA. Johnson AL. Potts 1.. Walwyn R, DeCesare JC, Baber HL, Burgess M, Clark LV, Cox DL, Bavinton J, Angus B], Murphy G, Murphy M, O?Dowd H, Wilks D, MrCrone P, Chalder T, Sharpe M; PACE Trial Management Group (2011). Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial.
Lancet 377. 823-836.

SUSANNA AGARDY c/o PO Box 6156, Hawthorn West PO 3122 (Email: susannaa@?)

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White and colleagues conclude from the results of the PACE trial that ?recovery from CFS (chronic fatigue syndrome) is possible, and that CBT (cognitive behavioural therapy) and GET (graded exercise therapy) are the therapies most likely to lead to recovery? (White et al. 2013).

However, in the body of the text, they qualify their use of the term ?recovery?. Citing Nisenbaum at al. (2003) they write, `recovery may be taken to imply that the patient has made a transition from ill health to remission and also is at little risk of recurrence? but then acknowledge that, in the absence of longitudi- nal data, it is not possible to discriminate between remission and recovery in CFS.

Thus, in the current paper, ?recovery? does not mean recovery as understood by Nisenbaum but `recovery from the current episode of the illness?, a state described by Nisenbaum as `remission?.

This difference is important because CFS is known to pursue ?a fluctuating course with periods of relative remission and relapse? (CFS/ME Working Group. 2002) and Cochrane reviews of CBT (Price et al. 2008) and GET (Edmonds et al. 2004) have reported inconsistent findings at long-term follow-up, with some studies showing that initial gains can diminish with time. Writing about the PACE trial, Edmonds et al. concluded `Even when the results of that study are available, it is possible that uncertainty will remain. Further randomized studies are needed, with longer follow-up, to determine whether patients who respond to exercise stay well or relapse.`

Declaration of Interest
None.

References
CFS/ME Working Group (2002). A Report of the CFS/ME Working Group: Report to the Chief Medical Officer of an Independent working group. Department of Health London. (http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/ dh_4064945.pdf).
Accessed 3 March 2013.

Edmonds M, McGuire H. Price JR (2004). Exercise therapy for chronic fatigue syndrome. Cochrane Database of Systematic Reviews. Issue 3. Art.No.CD003200. Nisenbaum R. Jones JF, Unger ER. Reyes M, Reeves WC (2003). A population-based study of the clinical course of chronic fatigue syndrome. Health and Quality of Life Outcomes 1, 49.

Price JR. Mitchell E, Tidy E. Hunot V (2008). Cognitive behaviour therapy for chronic fatigue syndrome in adults. Chochrane Database of Systematic Reviews. Issue 3. Art.No CD001027

White PD, Goldsmith K,]ohnson AL, Chalder T, Sharpe M; PACE Trial Management Group (20l3). Recovery from chronic fatigue syndrome after treatments given in the PACE trial.Psychological Medicine. Published online. 31 January 2013. doi:10.1017/S003329173000020

SAMUEL CARTER, M.A. (Oxon) (Email: sam.carter969@?)

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The main trial recovery criteria, described by White et al. (2013), allow participants with SF-36 physical function scores of >60 to be classed as recovered if, for example, their `main symptom? is no longer fatigue.

In terms of clinical interpretation, such a threshold is problematic because it is in conflict with how the condition itself is defined. For example, it indicates worse impairment than the PACE Trial entry criteria threshold of

Further, a score of

Declaration of Interest
None.

References
Reeves WC, Wagner D, Nisenbaurn R, Jones JF, Gurbaxani B Solomon L, Papanicolaou DA, Unger ER, Vernon SD, Helm C (2005). Chronic Fatigue Syndrome ? a clinically empirical approach to its definition and study. BMC Medicine 3, I9.

Stulemeijer M, de Jong LWAM, Fiselier T]W, Hoogveld SWB, Bleijenberg G (2004). Cognitive behaviour therapy for adolescents with chronic fatigue syndrome: randomised controlled trial. British Medical Journal 330, 14

van?t Levon M, Zielhuis GA, van der Meer ]W, Verbeek AL, Bleijenberg G (2009). Fatigue and chronic fatigue syndrome-like complaints in the general population. European Journal of Public Health 20, 251-257.

White PD, Goldsmith K,]ohnson AL, Chalder T, Sharpe M; PACE Trial Management Group (20l3). Recovery from chronic fatigue syndrome after treatments given in the PACE trial. Psychological Medicine. Published online. 31 January 2013. doi:10.1017/S003329173000020

White PD, Goldsmith KA. Johnson AL. Potts 1.. Walwyn R, DeCesare JC, Baber HL, Burgess M, Clark LV, Cox DL. Bavinton J, Angus B], Murphy G, Murphy M, O?Dowd H, Wilks D, MrCrone P, Chalder T, Sharpe M; PACE Trial Management Group (2011). Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 377. 823-836.

ROBERT COURTNEY (Email: information111@?)

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White et al. (2013) report various recovery rates from chronic fatigue syndrome (CFS) following the PACE Trial. However, additional information would have been useful.

White et al. use a selection of broad criteria to define recovery, none of which allow one to be confident recovery has been achieved. Firstly, Chalder Fatigue Questionnaire (CFQ) and SF-36 Physical functioning (PF) scores within the normal range are in fact possible at baseline. This means it is possible to have fatigue that is classed as `severe, disabling and affected physical and mental function? and yet satisfy this particular recovery criterion.

Secondly, not satisfying the Oxford criteria only requires a change on just one measure, and the change may be minimal, across a threshold, e.g. going from an SF-36 PF score of 65 to 70 or a CFQ (bimodal) score of 6 to 5. A sign that this criterion is not that stringent can be seen with the fact that 41% of the specialist medical care (SMC) group, which received no active treatment, no longer met the Oxford criteria at 12 months, much higher than recovery rates seen in previous studies (Cairns & Hotopf, 2005).

Finally, a CGI score of 2, which means a participant rated as `much better? but not `very much better? also gives no assurance that somebody had recovered. It seems quite possible that many with CGI scores of 2 have simply improved but not recovered.

Declaration of Interest
None.

References
Cairns R. Hotopf M (2005). A systematic review describing the prognosis of chronic fatigue Syndrome. Occupational Medicine 55, 20-31.

White PD, Goldsmith K, Johnson AL, Chalder T, Sharpe M; PACE Trial Management Group (2013). Recovery from chronic fatigue syndrome after treatments given in the PACE trial. Psychological Medicine . Published online. 31 January 2013. doi:10.1017/S003329173000020

DUNCAN COX
Warwickshire Network for M.E. (Email: warksmenet@?)

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It is debated whether cognitive behaviour therapy (CBT) or graded exercise therapy (GET) reliably facilitate recovery in chronic fatigue syndrome (CFS). As such, any data on this issue, such as those presented by White et al. (2013), are always of interest.

The trial was not blinded, however, with participants, therapists and research assessors aware of the treatment group for each individual (White et al. 2007). Consequently, there is the possibility of significant response bias. Indeed, while the CBT group performed better than the adaptive pacing therapy (APT) and the specialist medical care only (SMC) groups on the self-rated SF-36 physical functioning (SF-36 PF) scale, there were no significant differences and minimal numerical difference on the more objective six-minute walk distance test (6MWD) (White et al 2011).

This discrepancy between subjective and objective outcome measures is not a novel finding in the CFS literature. Wiborg et al. (2010) analysed three randomized control trials (RCTs) of three CBT interventions, finding that while fatigue was improved in the CBT groups compared to waiting-list controls, there was no difference in actometer readings between the two groups. Moreover, a mediation analysis showed changes in physical activity were not related to changes in fatigue. Similarly, in a GET RCT, Moss-Morris et al. (2005) found that an increase in physical fitness did not mediate the treatment effect of reduced fatigue. In an uncontrolled trial of a graded activity programme, Friedberg & Sohl (2009) reported improvements in SF-36 PF and fatigue while actometers showed overall reduction in total activity levels.

The 6MWD is one objective outcome measure White et al. (20l3) could have incorporated into their recovery criteria (White et al. 2007). Reference ranges for 6MWDs, which adjust for gender and age inter alia, exist for healthy adults (e.g. Chetta et al. 2006; Casanova et al. 2001). Then, after calculating the new recovery percentage with the 6MWDs, analyses could be preformed to compare the means with predicted values.

Declaration of Interest
None.

References
Casanova C, Celli BR, Barria P, Casas A, Cote C, de Torres JP, Jardim J, Lopez MV, Marin JM, Montes de Oca M, Pinto-Plata V, Aguirre-Jaime A; Six Minute Walk Distance Project (ALAT) (2011). The 6-min walk distance in healthy subjects: reference standards from seven countries. European Respiratory Journal 37, 150-6.

Friedberg F, Sohl S (2009). Cognitive-behavior therapy in chronic fatigue syndrome: is improvement related to increased physical activity? Journal of Clinical Psychology 65. 423-442.

Moss-Morris R. Sharon C, Tobin R, Baldi JC (2005). A randomized controlled graded exercise trial for chronic fatigue syndrome: outcomes and mechanisms of change. Journal of Health Psychology 10, 245-259.

White PD, Goldsmith K, Johnson AL, Chalder T, Sharpe M; PACE Trial Management Group (2013). Recovery from chronic fatigue syndrome after treatments given in the PACE trial. Psychological Medicine. Published online. 31 January 2013. doi:10.1017/S003329173000020

White PD, Goldsmith KA. Johnson AL. Potts 1.. Walwyn R, DeCesare JC, Baber HL, Burgess M, Clark LV, Cox DL. Bavinton J, Angus B], Murphy G, Murphy M, O?Dowd H, Wilks D, MrCrone P, Chalder T, Sharpe M; PACE Trial Management Group (2011). Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 377. 823-836.

White PD. Sharpe MC, Chalder T, DeCesare JC. Walwyn R; PACE trial group (2007). Protocol for the PACE trial: a randomised controlled trial of adaptive pacing. cognitive behaviour therapy, and graded exercise, as supplements to standardised specialist medical care versus standardised specialist medical care alone for patients with the chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy. BioMed Central Neurology 7, 6.

Wiborg JF, Knoop H, Stulemeijer M, Prins JB, Bleijenberg G (2010). How does cognitive behaviour therapy reduce fatigue in patients with chronic fatigue syndrome? The role of physical activity. Psychological Medicine 40, 1281-1287.

CARLY MARYHEW
(Email: maryhewc@gmail com)

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Important outcome data from the PACE trial (White et al. 2011) appears to be missing from the paper describing recovery in ME/CFS (White et al. 2013) and the participants do not appear to have been asked whether they had recovered as a result of receiving cognitive behaviour therapy (CBT), graded exercise therapy (GET) or Pacing.

The paper would have been improved had three speci?c markers of recovery been reported. First is the receipt of a state sickness or disability benefit. Claiming such a benefit indicates that the person is still ill and has not recovered. This data was included in the cost analysis study (McCrone et al. 2012) that reported: `Receipt of benefits due to illness or disability increased slightly from baseline
to follow-up.?

Second is employment or education status. The recovery paper argues that ?Return to work is not, however, an appropriate measure of recovery if the participant was not working before their illness and is in?uenced by other factors such as the job market.? However, a sustained return to meaningful paid employment, or education, or the ability to do so, is an objective marker of recovery.

Third is ability to mobilize. Recovery in a condition whose cardinal clinical features relate to mobility ? exercise-induced muscle fatigue and weakness ? must be matched with an ability to mobilize in a normal and timely manner. The overall results for all the treatments in the PACE trial relating to changes in the six-minute walking test from baseline to 52 weeks do not represent a return to normal levels of activity. It can be seen that the figure for all the treatment groups at 52 weeks are below the 402m reported to be present in patients with class 3 heart failure (Lipkin et al. 1986). So the results for those who had recovered ? who should now be achieving a much higher distance ? ought to have been included. In addition, the question could be raised as to how it is possible to meet the entry criteria for the PACE trial with a Short Form-36 physical function subscale score of 65 yet leave the trial as recovered with a lower score of 60.

The term `recovery? implies a sustained return to symptom-free health with the ability to repeatedly and reliably participate in all aspects of normal life ? employment, education, social activities. etc. Without this information it is difficult to conclude that these patients have in fact recovered.

Declaration of Interest
None.

References
Lipkin DP, Scriven A], Crake T, Poole-Wilson PA (I986). Six minute walking test for assessing exercise capacity in chronic heart failure. British Medical Journal (Clinical Research Edition) 292. 653.

McCrone P, Sharpe M, Chalder T, Knapp M, Johnson AL, Goldsmith KA, White PD (2012). Adaptive pacing, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome: a cost-effectiveness analysis PLoS One 2012. 7, e408084.

White PD, Goldsmith KA. Johnson AL. Potts 1.. Walwyn R, DeCesare JC, Baber HL, Burgess M, Clark LV, Cox DL. Bavinton J, Angus B], Murphy G, Murphy M, O?Dowd H, Wilks D, MrCrone P, Chalder T, Sharpe M (2011). Comparison of adaptive pacing therapy. cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised controlled trial. Lancet 377, 823-836.

White PD, Goldsmith K, Johnson AL, Chalder T, Sharpe M; PACE Trial Management Group (2013). Recovery from chronic fatigue syndrome after treatments given in the PACE trial. Psychological Medicine. Published online. 31 January 2013. doi:10.1017/S003329173000020

CHARLES SHEPHERD
Hon. Medical Adviser, ME Association (Email: charles.c.shepherd@?)

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REPLY

The de?nition of recovery from any chronic illness is challenging. We therefore agree with Cox (20I3) and Courtney (2013) that no single threshold measurement is sufficient; this is why we measured several domains of improvement and combined them into a composite measure of recovery (White et al. 20l3). Shepherd (2013) suggests asking patients whether they recovered as a result of [our italics] receiving a treatment; we did not ask this since it is not possible for individuals to ascribe change to one particular source in exclusion from all others, such as regression to the mean or external factors.

Maryhew (2013) suggests self-ratings may be biased when participants cannot be masked to treatment allocation; this may be true, but is inconsistent with cognitive behaviour therapy (CBT) being more effective than adaptive pacing therapy (APT) when treatment expectations were signi?cantly lower before treatment (White et al. 2011).

We dispute that in the PACE trial the six-minute walking test offered a better and more `objective? measure of recovery, as suggested by Agardy (2013), Maryhew (2013), and Shepherd (2013). First, recovery from chronic fatigue syndrome (CFS), which is defined by a patient?s reported symptoms, is arguably best measured by multiple patient-reported outcome measures, rather than a single performance test. Second, and importantly, there were practical limitations to our conduct of the walking test. Due to concerns about patients with CFS coping with physical exertion, no encouragement was given to participants as they performed the test, by contrast to the way this test is usually applied (Guyatt et al. I984; American Thoracic Society, 2002). Rather than encouragement, we told participants, `You should walk continuously if possible, but can slow down or stop if you need to.? Furthermore we had only 10 metres of walking corridor space available, rather than the 30-50 metres of space used in other studies; this meant that participants had to stop and turn around more frequently (Guyatt et al. I984; Troosters et al. I999; American Thoracic Society, 2002), slowing them down and thereby vitiating comparison with other studies. Finally, we had follow-up data on 72% of participants for this test, which was less than for the self-report measures (White et al. 2011).

Economic data, such as sickness bene?ts and employment status, have already been published by McCrone et al. (2012). However, recovery from illness is a health status, not an economic one, and plenty of working people are unwell (Oortwijn et al. 2011), while well people do not necessarily work. Some of our participants were either past the age of retirement or were not in paid employment when they fell ill. In addition, follow-up at 6 months after the end of therapy may be too short a period to affect either benefits or employment. We therefore disagree with Shepherd (2013) that such outcomes constitute a usefulcomponent of recovery in the PACE trial.

We agree with Carter (2013) that there is a difference between sustained recovery and temporary remission; this is why we were careful to give a precise definition of recovery and to emphasize that it applied at one particular point only and to the current episode of illness (White et al. 2013).

Despite the complexities of measuring recovery, we believe that our approach of using multiple self-report measures provides a reasonable approach to inform clinicians? and patients` choice between available treatments.

The ?ndings from the PACE trial are clear; however we measured recovery, CBT and graded exercise therapy (GET) were more likely to lead to recovery, when added to specialist medical care (SMC), compared to either adding APT or SMC alone. Recovery after SMC alone, using our composite criteria, was only 7% ? the same as that without treatment (Cairns & Hotopf, 2005) ? whereas three times as many (22%) recovered after receiving CBT or GET. The PACE trial has shown that both CBT and GET are moderately effective, safe, cost-effective, and are more likely to lead to recovery (White et al. 2011, 2013; McCrone et al. 2012). These treatments should now be routinely offered to all those who may benefit from them (Crawley et al. 2013].

Declaration of Interest
Declaration of interest is as stated in White et al. (2013).

References
Agardy S (2013). Comments on `Recovery from chronic fatigue syndrome after treatments given in the PACE trial? |letter]Psychological Medicine, doi:10.1017/S003329171300113X

American Thoracic Society (2002). ATS Statement: Guidelines for the six-minute walk test. American Journal of Respiratory and Critical Care Medicine 166, 111-117

Cairns R. Hotopf M (2005). A systematic review describing the prognosis of chronic fatigue Syndrome. Occupational Medicine 55, 20-31.

Carter S (2013). `Recovery from chronic fatigue syndrome after treatments given in the PACE trial?: recovery or remission? [letter] Psychological Medicine, doi:10.1017/ S0033291713001268

Courtney R (2013).`Recovery from chronic fatigue syndrome after treatments given in the PACE trial`: an appropriate threshold for a recovery? [letter]. Psychological Medicine, doi:10.1017/S003329171300127X

Cox D (2013). `Recovery from chronic fatigue syndrome after treatments given in the PACE trial?: data on the recovery groups as a whole would be useful [Letter]. Psychological Medicine. doi:10.1017/S0033291713001281

Crawley E, Collin SM, while PD, Rimes K. Sterne MC, May MT (1113;Treatment outcome in adults with chronic fatigue syndrome: a prospective study in England based on the CFS/ME National Outcomes Database. Quarterly Journal of Medicine. 28 March. doi: 10.1093/qjmed/hct061l.

Guyatt GH, Pugsley SO, Sullivan MJ, Thompson PJ, Berman LB, Jones. NL, Fallen EL, Taylor DW (1984) Effect of encouragement on walking test performance. Thorax 39 818-822

Maryhew C [Z013]. Comments on ?Recovery from chronic fatigue syndrome after treatments given in the PACE trial? [Letter] Psychological Medicine doi:10.1017/ S0033291713001293

McCrone P, Sharpe M, Chalder T, Knapp M, Johnson AL, Goldsmith KA, White PD (2012). Adaptive pacing, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome: a cost-effectiveness analysis PLoS One 7,e408084.

Oortwijn W, Nelissen E, Admini S, van den Heuvel S, Geuskens G, Burdof L. Social Determinants state of the art reviews- Health of People of Working Age ? Summary Report for Health and Consumers Luxembourg

Shepherd C (2013)Comments on `Recovery from chronic fatigue syndrome after treatments given in the PACE trial? [Letter]. Psychological Medicine doi:10.1017/ S003329171300113X

Troosters T, Gosselink R, Decramer M (1999) Six minute walking distance in healthy elderly subjects. European Respiratory Journal 14:270-274

White PD, Goldsmith KA. Johnson AL. Potts 1.. Walwyn R, DeCesare JC, Baber HL, Burgess M, Clark LV, Cox DL. Bavinton J, Angus B], Murphy G, Murphy M, O?Dowd H, Wilks D, MrCrone P, Chalder T, Sharpe M; PACE Trial Management Group (2011). Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial.
Lancet 377. 823-836.

White PD, Goldsmith K, Johnson AL, Chalder T, Sharpe M; PACE Trial Management Group (2013). Recovery from chronic fatigue syndrome after treatments given in the PACE trial. Psychological Medicine . Published online. 31 January 2013. doi:10.1017/S003329173000020

P.D.WHITE(1), K. GOLDSMITH(2), A. L. JOHNSON (3,4), T. CHALDER (5), M. SHARPE (6)
1 Wolfson Institute of Preventive Medicine, Barts and the London
School of Medicine and Dentistry, Queen Mary University of London, UK
2 Biostatistics Department, Institute of Psychiatry, King?s College
London, UK 3 MRC Biostatistics Unit, Institute of Public Health,
University of Cambridge, UK 4 MRC Clinical Trials Unit, London, UK 5
Academic Department of Psychological Medicine, King?s College London,
UK 6 Department of Psychiatry, University of Oxford, UK
(Email: p.d.white @ qmul.ac.uk)

Source: http://www.meassociation.org.uk/?p=16209

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Tornado Hits Ohio's Ursuline College; No One Hurt

A tornado packing 110 mph winds hit Ursuline College in northeast Ohio early Saturday morning, collapsing a wall of the school's athletic center and damaging other buildings but causing no injuries, officials said.

The EF1 twister hit about 3:35 a.m. northwest of the college and continued across part of the campus, said meteorologist William Comeaux of the National Weather Service in Cleveland. It reached 100-200 yards wide and traveled 1.3 miles.

Only a few students were on campus at the time, and they weren't close to the athletic center that was hardest hit, a college spokeswoman said.

"The blessing is that there was no loss of life or injury," Sister Diana Stano, president of the 1,500-student school about 13 miles east of Cleveland said on the college's website.

No one answered the main number for the college Saturday evening, but a recorded message said the campus was closed Saturday and Sunday to assess the damage.

The storm caused an external wall of the school's O'Brien Athletic Center to collapse and destroyed part of the roof. It also damaged several other buildings, including the Dauby Science Center and the Ralph M. Besse Library. Many trees were uprooted or destroyed and other campus facilities had minor damage.

College spokeswoman Angela DelPrete said only about five students were on campus at the time and they were about 1,000 feet from the gymnasium. She described debris scattered around the campus and broken windows. Weather service photos showed roof tiles torn away on the gymnasium exposing splintered wood and support beams.

Stano told The Plain Dealer that Ursuline was accepted as an NCAA Division II school only last week.

"Now we don't have a place to play," she said.

Ursuline was founded by Roman Catholic nuns as the first women's college in Ohio. Men now also attend the school.

Despite the damage Saturday, Comeaux said, "It's a beautiful area with lots of trees."

He said it's been about two years since a tornado has touched down in the region; the state averages 17-19 tornadoes per year. A disaster relief fund will be established to help rebuild the campus, the website said.

Source: http://feeds.abcnews.com/c/35229/f/654826/s/2ef11b27/l/0Labcnews0Bgo0N0CUS0CwireStory0Ctornado0Ehits0Eohios0Eursuline0Ecollege0Ehurt0E19725360A/story01.htm

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Longtime White House reporter Helen Thomas dies

By Vicki Allen and Bill Trott

WASHINGTON (Reuters) - Former White House correspondent Helen Thomas, a trailblazing journalist who reported on every U.S. president from John Kennedy to Barack Obama, died on Saturday at the age of 92, the Gridiron Club and Foundation said.

Thomas, who broke many barriers for female journalists during her 49 years on the White House beat for United Press International and Hearst newspapers and died after a long illness, the Washington journalists' organization said in a statement.

As the senior news service correspondent at the White House, Thomas ended dozens of presidential news conferences with the familiar phrase "Thank you, Mr. President."

She was known for her straight-to-the-point questioning of presidents and press secretaries in a manner that some considered dogged. Others, including many fellow reporters, considered her style in her later years to be too combative and agenda-driven.

President Barack Obama in a statement praised "her fierce belief that our democracy works best when we ask tough questions and hold our leaders to account," and noted that in her long tenure Thomas "never failed to keep presidents - myself included - on their toes."

Former President Bill Clinton and his wife, former Secretary of State Hillary Clinton, praised her as "a pioneering journalist" who added "more than her share of cracks to the glass ceiling."

In the last 10 years of her career Thomas was a columnist for Hearst, a job that allowed her opinions to surface more than in her work as a hard-news reporter for UPI.

Thomas announced in June 2010 that she was retiring from Hearst, effective immediately, after comments she made about Israel and the Palestinians, including that Israel should "get the hell out of Palestine," were captured on videotape and widely disseminated on the Internet.

Thomas later issued a statement: "I deeply regret my comments I made last week regarding the Israelis and the Palestinians. They do not reflect my heart-felt belief that peace will come to the Middle East only when all parties recognize the need for mutual respect and tolerance. May that day come soon."

Thomas believed the Washington media had grown soft and was reluctant to challenge government, views she shared in her 2007 book "Watchdogs of Democracy? The Waning Washington Press Corps and How It Has Failed the Public."

She was especially rough on former President George W. Bush, whom in 2003 she described as the "worst president ever," and the Iraq war, which she felt the media had abetted by not challenging Bush strongly enough on it.

In 2009 she asked Obama: "When are you going to get out of Afghanistan? Why are we continuing to kill and die there? What is the real excuse? And don't give us this Bushism 'If we don't go there, they'll all come here.'"

Veteran NBC News correspondent Andrea Mitchell on Saturday tweeted that Thomas "made it possible for all of us who followed," and Dana Perino, press secretary for George W. Bush, tweeted, "First day I ever took the podium she came to encourage me."

DEAN OF WHITE HOUSE MEDIA CORPS

Thomas was often combative in dealing with the White House, particularly when she felt she was being denied access. Reuters White House reporter Steve Holland recalled that early one morning during Clinton's presidency, she was spotted kicking the locked door to the White House press office, demanding to speak to the staff.

Thomas grew up in Detroit, the daughter of Lebanese immigrants, and will be buried in that city. Middle Eastern affairs were a strong interest and the impromptu comments about Israel and the Palestinians in May 2010 were her undoing.

Asked by an interviewer from the website rabbilive.com if she had any comments about Israel, Thomas responded, "Get the hell out of Palestine." She said Jews should "go home, to Poland and Germany, America and everywhere else."

After the interview spread on the Internet, her comments were criticized by the White House, the White House Correspondents' Association, the co-author of one of her books and the agency that handled her speaking engagements, among others. Shortly after, she announced her retirement, two months short of her 90th birthday.

Thomas established a number of firsts for women journalists in becoming one of Washington's best known reporters. She was the first woman officer in the White House Correspondents Association in its 50-year history, becoming its first woman president. In 1975, she broke the 90-year all-male barrier at the Gridiron Club, an organization of leading Washington journalists, and became its first female president in 1993.

She also supported scores of women starting out in the news business.

Thomas's career began as a copy girl on the Washington Daily News and she joined what was then known as United Press in 1943. She was assigned to the White House in 1961 in part because of the great interest in first lady Jacqueline Kennedy, as well as the new young president. She became UPI White House bureau chief in 1974, the first woman to head a wire service bureau there. She stayed in that position until 2000 when she joined Hearst.

Thomas first came to public notice during the Watergate era when she started receiving late-night phone calls from Martha Mitchell, the wife of Attorney General John Mitchell, discussing the scandal.

"I have witnessed presidents in situations of great triumph and adulation, when they are riding the crest of personal fulfillment, and I have seen them fall off their pedestals through an abuse of power or what President Clinton called 'a lapse of critical judgment,'" she wrote in her memoir "Front Row at the White House: My Life and Times."

Thomas married a professional rival, Douglas Cornell of the Associated Press, in 1971. He died in 1982.

(Reporting by Vicki Allen and Bill Trott; Editing by Jackie Frank and Mohammad Zargham)

Source: http://news.yahoo.com/long-time-white-house-reporter-helen-thomas-dies-141349325.html

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President Obama Gives Surprise Trayvon Martin Address

President speaks candidly on race in the United States and compares himself to the slain teenager.
By Brenna Ehrlich

Source: http://www.mtv.com/news/articles/1710926/president-obama-trayvon-martin.jhtml

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CBS Says Louisville Had The Best College Sports Year

Despite an unrivaled list of achievements that you can all recite subconsciously by now, Louisville failed to rank in the top 5 of either the final Capital One Cup or Director's Cup standings.

The formula for both of the awards is complicated and stupid, so CBS decided to put together its own formula to rank the top program performances across college athletics in 2012-13. As might be expected, the much more sensible formula wound up with the mighty Cardinals of U of L at No. 1.

For our formula -- which takes into account only schools that field FBS football programs -- we weighed football three times as much, while men's basketball is worth twice as many points as the other sports that are part of the formula. General fan and media interest in those sports, relative to the others that were part of our survey, informed that part of the formula.

Alabama's national title in football was worth 300 points. Notre Dame finished 4th in the final AP poll and was awarded 240 points. Football teams that finished with a winning record or went to a bowl game, but not in the final AP Top 25, received 75 points.

Louisville's national title in men's basketball was worth 200 points. Syracuse's Final Four appearance was worth 166, Ohio State in the Elite Eight was good for 146, and so on. Teams that finished with a winning record, but did not make the NCAA tournament, were given 10 points.

Here are the final standings:

Best in College Sports 2012-13
SCHOOL	FOOTBALL	MEN'S BB	WOMEN'S BB	BASEBALL	WILD CARD	TOTAL
1. Louisville	189	200	90	73	73	625
2. Oregon	270	128	0	50	64	512
3. Florida	207	146	10	25	100	488
4. Ohio State	255	146	10	0	73.5	484.5
5t. Michigan	150	180	50	0	78	458
5t. Oklahoma	180	50	64	64	100	458
7. Notre Dame	240	50	83	0	73	446
8. Alabama	300	10	0	25	85	420
9. Florida State	202.5	10	50	64	83	409.5
10. North Carolina	75	100	50	83	100	408
11. LSU	184.5	10	64	73	75	406.5
12. Texas A&M	222.75	10	50	50	64	396.75
13. Duke	75	146	73	0	100	394
Wild cards: Softball -- Texas A&M, Michigan, Oklahoma, Oregon; Men's lacrosse -- Duke; Women's gymnastics -- Alabama, LSU; Wrestling -- Ohio State; Women's soccer -- North Carolina, Florida State, Notre Dame; Women's gymnastics -- Florida; Men's soccer -- Louisville

As well as a feature piece on U of L from Dennis Dodd.

Source: http://www.cardchronicle.com/2013/7/19/4539002/cbs-says-louisville-had-the-best-college-sports-year

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U.S. Guarantees Israel?s Pre-1967 Borders Will Be Basis for Renewed Talks with Palestine, Officials Say

JERUSALEM (TheBlaze/AP) -- Israel's pre-1967 borders will be the basis of renewed peace talks between Palestine and Israel, according to a letter U.S. Secretary of State John Kerry gave to Palestinian President Mahmoud Abbas which guaranteed the stipulation.

After Abbas received the Kerry letter, he agreed to resume peace talks with Israel, two senior Palestinian officials said Saturday.

John Kerry, Mahmoud Abbas

U.S. Secretary of State John Kerry, left, meets with Palestinian President Mahmoud Abbas on Friday, July 19, 2013 in the West Bank city of Ramallah. Kerry stepped up his drive Friday to get Israelis and Palestinians back to the negotiating table, facing Palestinian reluctance over his formula for resuming peace talks after nearly five years. (Credit: AP)

The officials, both of whom are close to the Palestinian leader and privy to internal discussions, said the U.S. letter also stipulated that both sides are to refrain from taking any steps that would jeopardize the outcome of the talks.

Israel is not to issue new tenders for Jewish settlements in the West Bank, while the Palestinians are not to pursue diplomatic action against Israel at any international organizations, the officials said on condition of anonymity because they are not authorized to brief the media.

"The talks with Kerry were about to collapse, and the letter came as a lifeline in the last minute bargaining," one of the Palestinian officials said.

There was no immediate comment from the State Department, but U.S. officials have said in the past that Kerry would reiterate standing American positions on the goals for renewed talks, including that a Palestinian state should be negotiated on the basis of Israel's borders before the 1967 Mideast war, when Israel captured the Gaza Strip, West Bank and east Jerusalem.

After a round of intense shuttle diplomacy, Kerry announced on Friday that Israel and the Palestinians had agreed on a basis for returning to the peace process, which broke down five years ago. The two sides are to meet - likely in the coming week - to work out final details on actually resuming their negotiations on the toughest issues of the Israeli-Palestinian conflict.

Kerry would not give details on the agreement on the negotiations' framework. "The best way to give these negotiations a chance is to keep them private." he said. "We know that the challenges require some very tough choices in the days ahead. Today, however, I am hopeful."

The Palestinians long refused to return to the negotiating table unless Israel agreed to several preconditions, including that the talks be based on Israel's pre-1967 borders. Israel frequently called for talks to resume without preconditions, insisting that all core issues should be resolved through dialogue.

Speculation has been rife for weeks that the sides would find a way to sidestep Israel's reluctance to offer assurances of the 1967 lines as the framework for talks by having the guarantee provided by the United States.

Israeli Prime Minister Benjamin Netanyahu faces sharp opposition from within his majority coalition to such a move. One key ally, Economics Minister Naftali Bennett, has threatened to pull his Jewish Home Party out of the government altogether if the prime minister agrees to the border conditions.

NATANYAHU

Israeli Prime Minister Benjamin Netanyahu and his wife Sara wave national flags during the opening ceremony of The Maccabiah, the Jewish Olympic games held in Jerusalem under the auspices of the Maccabi Federation on July 18, 2013. (Credit: AFP/Getty) Images

The basis of the negotiations themselves - not the core issues at the heart of the conflict - has been a major impediment to resuming talks. On Thursday evening, the Palestinian leadership balked at dropping a main condition: They demanded a guarantee that negotiations on borders between a Palestinian state and Israel would be based on the cease-fire line that held from 1949 until the 1967 war.

Kerry's announcement late Friday suggested that the question had been resolved, although the top U.S. diplomat offered no details.

Netanyahu issued a statement Saturday evening welcoming Kerry's announcement and thanking him for his efforts, saying he "views the resumption of the political process at this time a vital strategic interest."

Earlier Saturday, Israel's intelligence and strategic affairs minister offered a few details on the framework. He confirmed that Israel would release some Palestinian prisoners, but said it will not meet other long-standing Palestinian demands before negotiations resume, such as a settlement freeze or defining the 1967 borders as the basis for talks.

Yuval Steinitz told Israel Radio that prisoners Israel has agreed to release include some who "have been sitting in jail for dozens of years," He did not say how many would be freed, adding only that they would be released in phases.

The fate of the prisoners is extremely sensitive in Palestinian society. After decades of fighting Israel, many families have had a member imprisoned and the release of prisoners has been a longstanding demand. The Palestinians are held on a range of charges, from rock throwing to deadly assaults like shooting attacks or bombings targeting Israeli soldiers and civilians. The Palestinians mostly view the prisoners as heroes while Israelis tend to see them as terrorists.

In a sign of the opposition Netanyahu faces even within his own government, deputy defense minister Danny Danon issued a statement condemning the prisoner release, saying "these murderers must not be released as an `act of good will' or as a prize for returning to the negotiating table."

Danny Danon

In this photograph made on Thursday, June 27, 2013, Israeli Deputy Minister of Defense Danny Danon speaks during an interview to the Associated Press in his office in Tel Aviv, Israel. Danon says he has no problem with his party leader, Israel's prime minister, so long as he doesn't make peace. The ambitious deputy defense minister isn't a household name internationally yet, but at home he has emerged as an unlikely opponent to Benjamin Netanyahu and his strongest opposition within the hawkish ruling Likud Part. (Credit: AP)

Steinitz said it a nine-month timetable was agreed to for the talks to prevent them from collapsing along the way. He also said the Palestinians agreed to refrain from taking action against Israel at the United Nations while the talks are taking place - echoing the statement from the Palestinian officials.

Israel's chief negotiator with the Palestinians, Tzipi Livni, welcomed the revival of the peace process. She said it was difficult to restart talks after years of mistrust between the sides, but that she is "hopeful" about them.

"This is a very heavy responsibility," Livni told Israel's Channel 2 TV of the talks. "All the issues will be on the table."

Final status negotiations aim to reach a deal on the core issues of the Israeli-Palestinian conflict, including Jerusalem, borders, the fate of Palestinian refugees and security arrangements. Talks ground to a halt five years ago, and previous efforts to revive them have stalled, particularly over Palestinian demands that Israel announce a freeze in construction of Jewish settlements in the West Bank and east Jerusalem, which they claim as part of a future state along with Gaza. Israel withdrew from Gaza in 2005.

In Gaza, Hamas spokesman Sami Abu Zuhri said his group rejects Kerry's announcement, saying it does not recognize Abbas' "legitimacy to negotiate" on their behalf. The militant Hamas group rules Gaza, and has been at odds with Abbas since taking over the seaside strip in 2007.

Here's a report on the issue of releasing Palestinian prisoners, via CBS News:

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Source: http://news.yahoo.com/u-guarantees-israel-pre-1967-borders-basis-renewed-220412170.html

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Candidates make final appeal in Japan election

TOKYO -- Candidates for the upper house of Japan's parliament made final campaign pushes Saturday, a day before elections that Prime Minister Shinzo Abe's ruling coalition is expected to easily win as the economy picks up steam.

A victory Sunday would give Abe's Liberal Democratic Party and junior partner New Komeito control of both houses of parliament ? an elusive goal for the government in recent years ? making it easier to pass legislation at a time when Japan faces huge structural challenges, including a rapidly graying population and bulging national debt.

Reviving the long-stagnant economy is the top priority for voters, and Abe agrees. Aggressive monetary easing and public works spending ? the first two "arrows" of his three-pronged "Abenomics" economic program ? has so far borne some fruit, lifting the stock market, boosting business confidence and easing pressure on Japan's vital exporters by weakening the yen.

Major economic challenges lay ahead, including Abe's promises to carry out economic reforms aimed at increasing Japan's competitiveness ? the third "arrow" ? and a decision this fall on whether to follow through on raising the sales tax next April from 5 percent to 8 percent ? a move some warn will derail the fledgling recovery.

A convincing victory in Sunday's election, where half the 242 seats in the less powerful upper house of parliament are up for grabs, may also embolden Abe and his backers in the LDP to pursue a nationalistic agenda he had abandoned his first time in office in 2006-2007.

Abe and others in the increasingly right-wing LDP have said they would like to revise the country's pacifist constitution, drafted by the United States after World War II, to give Japan's military a larger role and make changes to the education system to instill more patriotism in students.

Under the campaign slogan "Recover Japan," the LDP promises to make Japan a muscular, gentle and proud country. It calls for a strong economy, strategic diplomacy and unshakable national security under the Japan-U.S. alliance, which allows for 50,000 American troops to be stationed in Japan.

That message has resonated with some voters worried about tensions over territorial disputes with China and South Korea and widespread distrust of an increasingly assertive China. A recent survey by Pew Research Center showed that only 5 percent of Japanese have a favorable opinion of China.

Perhaps the most significant revision proposed by the LDP is relaxing the constitution's war-renouncing Article 9, which bans the use of force in international disputes except for self-defense. A revision could open the way for Japan to have full-fledged armed forces and make territorial protection a public duty.

Stepping up nationalistic rhetoric or taking steps to expand the role of Japan's military will likely further strain ties with major trading partners China and South Korea. Abe has already upset both neighbors since taking office in December by saying he wanted to revise Japan's 1995 apology for its wartime aggression and questioning the extent to which Korean, Chinese and other Asian women were coerced to provide sex for Japanese soldiers before and during World War II.

Revising the constitution is a lengthy process that requires two-thirds approval of both houses of parliament and a national referendum. With economic concerns uppermost, it remains to be seen whether Abe and parliament will be able to devote the considerable time and energy required to tackle such matters.

Surveys show that the public is most concerned about the economy, social security, the sales tax hike and reconstruction after the March 2011 tsunami. Two-and-a-half years after that disaster, very little rebuilding has begun along the battered northeastern coastline.

Public support for changing the constitution ranks lower.

Energy issues such as nuclear power are less important to voters, polls show. Despite considerable public opposition to nuclear power in the wake of the 2011 Fukushima disaster, many voters appear to be willing to support the pro-nuclear LDP because they are attaching a higher priority on economic and security issues.

Source: http://www.miamiherald.com/2013/07/20/3510413/candidates-make-final-appeal-in.html

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