CFS safety and care for those with physiological abnormalities and symptoms, recovery, improvement, objective measures, long term outcomes, heart rate monitoring, cause of CFS

The request was refused by University of Bristol.

Dear University of Bristol,

I seek information on:
i) The rational for trials of Graded Exercise Therapy (GET) and Cognitive Behaviour Therapy in children. Since, GET and CBT are harmful in adults and not statistically effective on either subjective or objective measures in large scale, multi pound studies known as the PACE and FINE studies on adults (see notes below).

ii) The possible causes, nature and course of CFS/ME, as provided to clients on or after 1 December 2016, at the clinics (as required by NICE Guidelines).

iii) The rational for trial children NOT monitoring their heart rates. NICE Guidelines require heart rate monitoring.

iv) Definition of recovery from CFS, used at the clinics.

v) Definition of significant improvement, used at the clinics.

vi) Long term outcomes of children attending the clinics, whatever statistics are collected but nominally at 2, 5 and 10 years.

vii) The measures used by the clinics to determine that a child is sufficiently well to no longer needs the clinics services.

viii) Advice provided to Ester Crawley by Bristol Universities exercise physiologists (or other experts in a relevant field) on the trial design and content.

ix) The basis for NOT including any objective measures of outcomes, trials of using Graded Exercise Therapy (GET) and Cognitive Behaviour Therapy (CBT), to "treat" children with CFS.

x) Whether or not children with each of the following signs and symptoms of CFS, are identified at the clinics and in the trial cohorts:
a) Abnormally low anaerobic thresholds (found by Mark VanNess et al in adults with ME/CFS);
b) Chronotropic incompetence (found by Mark VanNess et al in adults with ME/CFS);
c) Abnormally elevated heart rates after exertion (ICC and CCC);
d) Low temperature after exertion (ICC, CCC);
e) Abnormally low daily temperature (ICC, CCC).
f) Orthostatic intolerance (ICC, CCC, CDC, IOM).
g) Elevated or reduced true resting heart rate in response to exertion (ICC, CCC).
h) Worsening heart rate variability in response to exertion (Adult patients).
i) Less gross and net oxygen uptake, compared to healthy children when walking (University of Glasgow).
j) Abnormalities on the second day of the, 2 day CPET test (Mark Van Ness et al)
k) Abnormal rhomberg or other neurological test (ICC, CCC, Dr, Lucinca Bateman).
l) Poor cognitive function (ICC, CCC and many publications).
m) Food intolerance (ICC, CCC).
n) Chemical intolerance (ICC,CCC).
o) Light, noise and heat intolerance (ICC, CCC).

xi) How children with the above (at request x) signs and symptoms of CFS, are cared for and the measures and practices in place to address their symptoms and quantifiable physiological abnormalities.

Yours faithfully,

George Jenson

NOTES:
One : The trial protocols, of Ester Crawley, rely heavily on the PACE trial outcomes, to justify being worthwhile. However, the outcomes of the PACE trial have been found to be severely misleading and flawed. http://me-pedia.org/wiki/PACE_trial. (Peter White, Trudie Chaldler, Michael Sharpe, Simon Wessley – have not addressed the flaws in the trial and admitted on the QMUL website, that by changing the trial protocol they overstated the effectiveness of CBT and GET). In fact GET and CBT have never been shown to be effective on OBJECTIVE meaures are are now known to be NOT effective on subjective measures, by the outcomes of the PACE and FINE trials. In addition a number of surveys by patient charities, have found GET and CBT harmful (MEAssociation etc..).

Two: The NICE Guidelines are silent on the physiological abnormalities found in people with CFS, that are documented in the Canadian (CCC) and International Consensus Criteria (ICC) for ME/CFS and objectively determined by Mark VanNess et al. as per his talk at the Bristol Watershed. https://www.youtube.com/watch?v=q_cnva7z...
This means that an unkown number of children with the abnormalties described in the CCC/ICC are included in the NICE cohort for CFS, and attend the CFS clinics under the auspices of Esther Crawley.

The trial protocols by Esther Crawley are silent on how children with the physiological abnormalities described in the CCC and ICC and by Mark VanNess, are to be cared for and managed.

The information I seek information is NOT contained in the trial protocols.

University of Bristol FOI mailbox, University of Bristol

Thank you for your email.
The University will respond to requests under the Freedom of Information
Act within 20 working days. We may need to ask you certain questions to
clarify your request to ensure we fully understand what information is
being requested. If so, the 20 working day deadline will be calculated
once we have received such clarification. 
The University's A-Z index can help in locating information that is
publicly available on the University's
website: [1]http://www.bristol.ac.uk/index/
Our Publication Scheme is available
at: [2]http://www.bristol.ac.uk/media-library/s...
The Higher Education Statistics Agency (HESA) annually publish certain
data about students and higher education, and also have a bespoke data
request service: [3]https://www.hesa.ac.uk/
For further information about the University's FOI procedure, please
see: [4]http://www.bristol.ac.uk/secretary/foi/

--
Review procedure
If you are not satisfied with the University’s response to your request
you may ask the University to review the response by writing to:
Director of Legal Services
Secretary’s Office
University of Bristol 
Senate House
Tyndall Avenue
Bristol BS8 1TH 
Email: [5][University of Bristol request email] 
enclosing a copy of your original request and explaining why you are
requesting a review. The full review procedure is set out at:
 [6]http://www.bristol.ac.uk/secretary/foi/r...
Your request for internal review should be submitted to us within 40
working days of receipt of a response.  
If you are not satisfied with the outcome of the internal review you may
also contact the Information Commissioner’s Office at: 
Wycliffe House
Water Lane
Wilmslow
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SK9 5AF
[7]www.ico.gov.uk 
Best wishes
Freedom of Information Team
University of Bristol

References

Visible links
1. http://www.bristol.ac.uk/index/
2. http://www.bristol.ac.uk/media-library/s...
3. https://www.hesa.ac.uk/
4. http://www.bristol.ac.uk/secretary/foi/
5. mailto:[University of Bristol request email]
6. http://www.bristol.ac.uk/secretary/foi/r...
7. http://www.ico.gov.uk/

Dear University of Bristol,

I am still waiting for a response to my FOI request on how Bristol University cares/measures the physical aspects of the health of clients with chronic fatigue syndrome.

Yours faithfully,

George Jenson

University of Bristol FOI mailbox, University of Bristol

Thank you for your email. The University will respond to requests under
the Freedom of Information Act within 20 working days. We may need to ask
you certain questions to clarify your request to ensure we fully
understand what information is being requested. If so, the 20 working day
deadline will be calculated once we have received such clarification. 
The University's A-Z index can help in locating information that is
publicly available on the University's
website: [1]http://www.bristol.ac.uk/index/
Our Publication Scheme is available
at: [2]http://www.bristol.ac.uk/media-library/s...
The Higher Education Statistics Agency (HESA) annually publish certain
data about students and higher education, and also have a bespoke data
request service: [3]https://www.hesa.ac.uk/
For further information about the University's FOI procedure, please
see: [4]http://www.bristol.ac.uk/secretary/foi/

--
Review procedure
If you are not satisfied with the University’s response to your request
you may ask the University to review the response by writing to:
Director of Legal Services
Secretary’s Office
University of Bristol 
Senate House
Tyndall Avenue
Bristol BS8 1TH 
Email: [5][University of Bristol request email] 
enclosing a copy of your original request and explaining why you are
requesting a review. The full review procedure is set out at:
 [6]http://www.bristol.ac.uk/secretary/foi/r...
Your request for internal review should be submitted to us within 40
working days of receipt of a response.  
If you are not satisfied with the outcome of the internal review you may
also contact the Information Commissioner’s Office at: 
Wycliffe House
Water Lane
Wilmslow
Cheshire
SK9 5AF
[7]www.ico.gov.uk 
Best wishes
Freedom of Information Team
University of Bristol

References

Visible links
1. http://www.bristol.ac.uk/index/
2. http://www.bristol.ac.uk/media-library/s...
3. https://www.hesa.ac.uk/
4. http://www.bristol.ac.uk/secretary/foi/
5. mailto:[University of Bristol request email]
6. http://www.bristol.ac.uk/secretary/foi/r...
7. http://www.ico.gov.uk/

University of Bristol FOI mailbox, University of Bristol

Dear George Jenson,

 

Freedom of Information Act Request:  CFS safety and care for those with
physiological abnormalities and symptoms, recovery, improvement, objective
measures, long term outcomes, heart rate monitoring, cause of CFS
(FOI17-69)

 

The University of Bristol has considered your request for information
entitled “ CFS safety and care for those with physiological abnormalities
and symptoms, recovery, improvement, objective measures, long term
outcomes, heart rate monitoring, cause of CFS?” dated 11 December 2017
submitted through the website ‘[1]whatdotheyknow.com’

 

Refusal notice under section 17 of FOIA

 

The University is refusing your request on the grounds of section 14 as
we consider your request to be a vexatious and repeated request.

 

Having considered your request in the chain of correspondence staring the
11 December 2016, the University considers this request to be a part of a
campaign of identical and similar requests that the University has
received over the preceding months which is likely to cause a
disproportionate or unjustified level of disruption to the University and
irritation or distress to our staff

 

The University has given due consideration to the guidance issued by the
Information Commissioners Office on vexatious and repeated requests.  A
copy of which is available from the following
link  [2]https://ico.org.uk/media/for-organisatio...

 

In reaching this conclusion we have taken into account that your request
focuses on seeking opinions as opposed to information, and that the
University has already responded to a substantially similar request from
submitted on the 1^st November 2016. 

 

We have also taken into account the contents of your request which is
substantially similar to 9 other chains of requests received through the
website ‘Whatdotheyknow.com’ since the 1^st November 2016.

 

[3]https://www.whatdotheyknow.com/request/c...

 

[4]https://www.whatdotheyknow.com/request/c...

 

[5]https://www.whatdotheyknow.com/request/c...

 

[6]https://www.whatdotheyknow.com/request/c...

 

[7]https://www.whatdotheyknow.com/request/m...

 

[8]https://www.whatdotheyknow.com/request/c...

 

[9]https://www.whatdotheyknow.com/request/c...

 

[10]https://www.whatdotheyknow.com/request/c...

 

[11]https://www.whatdotheyknow.com/request/c...

 

Internal Review Procedure

 

If you are dissatisfied with the handling of your request then you have a
right under Section 50 of the Act to request an internal review.  All such
requests must sent to us within 40 days and must clearly state your
reference number and your reason for your request for an internal review. 
We will respond to your request for an internal review within 20 working
days of receipt.

 

Your request for an internal review should be sent to:-

 

Director of Legal Services,

Secretary’s Office,

University of Bristol,

Senate House,

Tyndall Avenue,

Bristol,

BS8 1TH

 

Or you can email your request to [12][University of Bristol request email],
quoting your FOI reference number at the head of this letter.

 

Information Commissioners Office

 

Should you remain dissatisfied with the final outcome of the internal
review then you may apply directly to the Information Commissioner (the
“ICO”) for an independent review.  The ICO is the Government’s Independent
Body responsible for overseeing the Freedom of Information Act 2000, the
Data Protection Act 1998 and The Environmental Information Regulations
2004.

 

Please note the ICO will only review cases that have exhausted the
University’s internal review procedure. All correspondence to the ICO must
quote the University’s reference number and your reasons for your appeal. 
The ICO’s contact details are as follows:-

 

The Information Commissioners Office,

Wycliffe House,

Water Lane,

Wilmslow,

Cheshire,

SK9 5AF.

Best wishes

 

Freedom of Information Team

University of Bristol

show quoted sections

Dear University of Bristol FOI mailbox,

It is not clear why the university supports the lack of transparency and hiding of information on the effectiveness of its chronic fatigue clinics.

It is quite unfitting for a University to reject scientific progress, physiology and objective science. Instead of openness and transparency supporting mumbo jumbo and practices based on pseudo science.

It is not a lot of work or a disproportionate amount of work to release outcome statistics on the performance of it's chronic fatigue syndrome clinic?

Why is it so hard to obtain basic outcome information on the CFS clinic outcomes?

Clinics such as the Workwell Foundation have a 100% success rate in that all patients improve their quality of life on OBJECTIVE measures leading to subjective improvements as well. This is because they base theory and programs on patient physiology and heart rate response to exertion.

I am not asking the clinic to generate any new information merely to release to the tax payer, who after all fund the clinic its outcome measures that it keeps as the natural course of business.

Yours sincerely,

George Jenson

University of Bristol FOI mailbox, University of Bristol

1 Attachment

Dear Mr Jenson,
Please see the attached response to your email of 10 April 2017 requesting
an internal review of the University of Bristol's handling of your
requests for information about CFS safety and care for those with
physiological abnormalities and symptoms, recovery, improvement, objective
measures, long term outcomes, heart rate monitoring, cause of CFS
Freedom of Information Team
University of Bristol

show quoted sections

Dear University of Bristol FOI mailbox,

The fact that a number of people have requested information on Bristol Universities chronic fatigue syndrome clinics, is surely a reflection of the lengths that the University is prepared to go to hide from the biomedical research and findings of USA government agencies.
The fact that a number of people want the same information is hardly surprising since you haven't released any information, on:
-"CFS safety and care for those with physiological abnormalities and symptoms, recovery, improvement, objective measures, long term outcomes, heart rate monitoring, cause of CFS?"
or similar data requests.

My request was made because of the likihood of long term and severe harm caused by misleading parents with claims of recovery and claims that their child ending up bedridden during treatment, is an expected adverse effect.

Any worsening of symptoms is 100% indicative of poor management of physical/emotional/mental stressors.

Yours sincerely,

George Jenson

University of Bristol FOI mailbox, University of Bristol

Thank you for your email. The University will respond to requests under
the Freedom of Information Act within 20 working days. We may need to ask
you certain questions to clarify your request to ensure we fully
understand what information is being requested. If so, the 20 working day
deadline will be calculated once we have received such clarification. 
The University's A-Z index can help in locating information that is
publicly available on the University's
website: [1]http://www.bristol.ac.uk/index/
Our Publication Scheme is available
at: [2]http://www.bristol.ac.uk/media-library/s...
The Higher Education Statistics Agency (HESA) annually publish certain
data about students and higher education, and also have a bespoke data
request service: [3]https://www.hesa.ac.uk/
For further information about the University's FOI procedure, please
see: [4]http://www.bristol.ac.uk/secretary/foi/

References

Visible links
1. http://www.bristol.ac.uk/index/
2. http://www.bristol.ac.uk/media-library/s...
3. https://www.hesa.ac.uk/
4. http://www.bristol.ac.uk/secretary/foi/

Dear University of Bristol,

My request is overdue, do you want anymore information?
It is 20 years since Peter White first had success with exercise programs based on 40% of VO2 max for patients with CFS.
Mark VanNess visted Bristol and detailed why the early work of PD White, that used physiological data (low intensity activity at 40% of VO2 max, and heart rate monitoring) to manage CFS patient care was sucessful and has determined that people with CFS have an abnormally low anaerobic threshold.
Ester Crawley is a close colleague of Peter Whites and I'm very interested in how this avenue of research has progressed in the past 20 years.

Yours faithfully,

George Jenson

University of Bristol FOI mailbox, University of Bristol

Dear Mr Jenson,

We acknowledge receipt of your email.

For the reasons previously advised in our earlier correspondence we will
not be considering your request further.

Freedom of Information Team

University of Bristol 

show quoted sections

University of Bristol FOI mailbox, University of Bristol

Dear Mr Jenson,

We acknowledge receipt of your email.

For the reasons previously advised in our earlier correspondence we will
not be considering your request further.

Freedom of Information Team

University of Bristol 

show quoted sections

Dear University of Bristol FOI mailbox,

Odd when seeking outcome data in relation to a clinic that describes children becoming bedridden during "treatment" as vexatious. When requests narrowed down are labelled "repeated request". Then again I was told that Bristol University staff are now giving talks on how to avoid releasing information at medical conferences.

Yours sincerely,

George Jenson

University of Bristol FOI mailbox, University of Bristol

Thank you for your email. The University will respond to requests under
the Freedom of Information Act within 20 working days. We may need to ask
you certain questions to clarify your request to ensure we fully
understand what information is being requested. If so, the 20 working day
deadline will be calculated once we have received such clarification. 
The University's A-Z index can help in locating information that is
publicly available on the University's
website: [1]http://www.bristol.ac.uk/index/
Our Publication Scheme is available
at: [2]http://www.bristol.ac.uk/media-library/s...
The Higher Education Statistics Agency (HESA) annually publish certain
data about students and higher education, and also have a bespoke data
request service: [3]https://www.hesa.ac.uk/
For further information about the University's FOI procedure, please
see: [4]http://www.bristol.ac.uk/secretary/foi/

References

Visible links
1. http://www.bristol.ac.uk/index/
2. http://www.bristol.ac.uk/media-library/s...
3. https://www.hesa.ac.uk/
4. http://www.bristol.ac.uk/secretary/foi/

University of Bristol FOI mailbox, University of Bristol

Dear Mr Jenson,

 We acknowledge receipt of your email.

 For the reasons previously advised in our earlier correspondence we
will not be considering your request further.

 
Freedom of Information Team
University of Bristol 

show quoted sections

Dear University of Bristol FOI mailbox,

Ester Crawly's recent talk/slides to the British Renal Society clearly described the approach that Bristol University enables her to take to FOI requests and how to keep data hidden from independent researchers.

I put it to you that your consideration of my request for information has not been undertaken in good faith and that any old excuse would have and is used by Ester Crawly to keep the objective outcomes of children at her clinics hidden from parents and independent researchers outside the mental health cohort.

Why is so much secrecy around the outcomes at the clinic?

Yours sincerely,

George Jenson

University of Bristol FOI mailbox, University of Bristol

Thank you for your email. The University will respond to requests under
the Freedom of Information Act within 20 working days. We may need to ask
you certain questions to clarify your request to ensure we fully
understand what information is being requested. If so, the 20 working day
deadline will be calculated once we have received such clarification. 
The University's A-Z index can help in locating information that is
publicly available on the University's
website: [1]http://www.bristol.ac.uk/index/
Our Publication Scheme is available
at: [2]http://www.bristol.ac.uk/media-library/s...
The Higher Education Statistics Agency (HESA) annually publish certain
data about students and higher education, and also have a bespoke data
request service: [3]https://www.hesa.ac.uk/
For further information about the University's FOI procedure, please
see: [4]http://www.bristol.ac.uk/secretary/foi/

References

Visible links
1. http://www.bristol.ac.uk/index/
2. http://www.bristol.ac.uk/media-library/s...
3. https://www.hesa.ac.uk/
4. http://www.bristol.ac.uk/secretary/foi/

University of Bristol FOI mailbox, University of Bristol

Dear Mr Jenson,
We acknowledge receipt of your email.

For the reasons previously advised in our earlier correspondence
we will not be considering your request further.

  
Freedom of Information Team
University of Bristol 

show quoted sections

University of Bristol FOI mailbox, University of Bristol

Dear Mr Jenson,

We acknowledge receipt of your email.
For the reasons previously advised in our earlier correspondence
we will not be considering your request further.
Freedom of Information Team
University of Bristol 

show quoted sections

Dear University of Bristol FOI mailbox,

I note your comment that I have made repeated requests. As you can see by my requests, I have tried various angles to frame my request in a manner that at least some information is forth coming to no avail.

Ester Crawleys talk to the British Renal Society on how to thwart FOI requests made it clear that regardless of the merit of any request for information will be refused.

This is at odds with science, particularly when the work by Ester Crawly contains serious flaws and her claims of outcomes are unfounded. Patients are well aware that her claims of success and recovery are at odds with patients/parents experience, are well aware that in hiding data Bristol University is complicit in causing harm to unknown numbers of children. A read of the FitNet protocol cites a child becoming bedridden as an expected adverse event . ME/CFS is made worse by exertion that child that was able to leave the house and is now bedridden is bedridden due to too much exertion. It will takes many months or weeks for the child to recover- the deterioration in health can be measured by the changes in heart rate abnormalities and metabolic changes .

It appears that the protection of Ester Crawly's belief system and dodgy research in which she conflates the severe and devastating neurological disease chronic fatigue syndrome with many physiological and biomedical abnormalities with one of its milder symptoms ie chronic fatigue, takes priority over the health of Bristol's children.

Prof David Tuller will in the UK on 1 June talking in person about the flaws and faults in EC and the PACE authors "research" and their faulty belief system.

Maybe Bristol University will see fit to send an independent person along to Prof. David Tullers talk?

The complaints about EC are widespread and deep, she appears to claim these as "badges of honor" ignoring the calls for her to either start doing high quality research or leave the field.

It is very disappointing that Bristol University is unable to look at the facts and science of the matter and unwilling to help patients and parents.

Yours sincerely,

George Jenson

Trial By Error, Continued: The CMRC Affirms Full Support for Libelous Esther
15 MAY 2017
By David Tuller, DrPH

For the last couple of weeks, I have been hammering the CFS/ME Research Collaborative to take a position on the actions of its deputy chair, Libelous Esther—better known as Dr. Esther Crawley. As I reported in several previous posts, Dr. Crawley falsely accused me of writing “libelous blogs” and Dr. Racaniello of posting them. To keep members of the CMRC board in the loop, I have sent them e-mails with links to these posts. In these e-mails, I have tried to be direct and pointed, but reasonably polite. I have mostly succeeded, although the recipients might have their own perspective.

At first, the CMRC refused to respond at all. Then the chair of the board, Stephen Holgate, sent me what could only be interpreted as a “f**k off” message. He told me that Dr. Crawley’s actions had nothing to do with the CMRC because it was just a “voluntary” group of colleagues with “no official standing.” Therefore, he wrote, I had to pursue my concerns through “other avenues.”

To me, “other avenues” meant more blogging about the false accusations of libel and the CMRC’s inadequate response, among other things. So I wrote yet another post about L’Affaire Crawley, noting the CMRC’s explanation that it could not possibly take a position because it was only a voluntary group with “no official standing.” I duly sent this post to the CMRC board.

And on Friday, I finally received from Dr. Holgate an enthusiastic endorsement of Dr. Crawley and her work. The statement made no mention of her recent multi-media spectacle, including her false libel accusation and her portrayal of legitimate requests for information as “vexatious.” In other words, the CMRC has sent me its second “f**k off” message. Happy International ME Awareness Day!

Here’s Dr. Holgate’s e-mail:

Dear David,

Prof Esther Crawley has the full support of the CMRC Executive Board in her role as Vice-Chair. The CMRC exists to promote the highest quality of basic and applied evidenced-based and peer-reviewed research into CFS/ME and Prof Crawley helps us to do this. Prof Crawley’s science is tested through the demanding procedures that all scientists must face when seeking grant-funding and publication in leading journals. The high quality of her research is recognised by her peers and she is a Professor of Child Health at the University of Bristol and an NIHR Senior Research Fellow. She is the clinical lead for the specialist child CFS/ME service at the Royal United Hospital in Bath and, sadly, is one of very few scientists in the UK actively trying to find a way to help children affected by CFS/ME. Contrary to some claims this collaborative is not fixated on any one cause, therapy or branch of science – our only goals are to improve our understanding of this serious illness and help alleviate suffering. In the meantime, our work remains focused on increasing collaboration and funding for more research and we will continue to work with all key stakeholders to achieve this.

Yours,
Stephen

I wrote back to Stephen and other board members that I took his answer to be an endorsement of Dr. Crawley’s actions and her false libel accusation. I noted that PACE, like Dr. Crawley’s research, had also been “tested through the demanding procedures” required of scientists. Given that PACE was a disaster, I pointed out, I didn’t hold those “demanding procedures” in as high regard as he did. I again noted the serious flaws in Dr. Crawley’s research.

Finally, I let Stephen and the CMRC board members know that I would be discussing the PACE mess and the Crawley situation, including their own role, during my talk on June 1 at the Invest in ME conference dinner. I included a link to the dinner information, in case any of the CMRC board members wanted to attend.

*****

On a related issue, a number of people have urged me to sue Dr. Crawley. I have made it clear I’m not going to do that. Not because she doesn’t deserve it, but because I don’t deserve it. Lawsuits are hell for everyone. The opportunity costs in time, money, and energy are incalculable. Except for Donald Trump and attorneys, no one who has ever been involved in a lawsuit would ever want to be involved in another one. (Of course, not filing a lawsuit does not mean I can’t file complaints with her university and medical regulators.)

There are other excellent reasons not to pursue that route. For one, by taking legal action off the table, I occupy the moral high ground. That allows me to slam Dr. Crawley and the CMRC for their awful behavior as much as I want.

For another, and here’s the real challenge, I would have to prove that Dr. Crawley’s false accusation has actually caused me harm. Dr. Crawley has had tremendous influence over the health and lives of people with ME/CFS, especially in the U.K., but she has no power over me. I cannot honestly argue that her behavior, however distasteful, has damaged my reputation, caused me anxiety or led to economic loss. On the contrary, she’s given me great material to blog and talk about, complete with an excellent slide-show that documents her unprofessional behavior. Going forward, this stunt of Dr. Crawley’s and the resulting visuals are likely to haunt her career and inflict permanent damage on her reputation.

Now If I were to suffer a renal emergency in the UK and no nephrologists would see me because they had heard Dr. Crawley’s false accusation of libel, then I might be able to argue that I had suffered actual damage. Until then, no. (I do have a history of kidney stones and I am coming to the U.K. soon, but I don’t think she‘s gotten to the urologists yet.)