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There were 25 Indian Health Service hospitals in our database, which we excluded from the analysis due to the special characteristics of the prospective payment methodology for these hospitals

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[2] Nervous system Brain Progressive brain changes [3] Central nervous system increased ventricular lactate [4] [5] [6] [7] neuroinflammation [8] [9] [10] [11] reduced grey [12] and white matter [3] [12] widespread metabolite abnormalities [10] Autonomic nervous system Peripheral nervous system Muscular system mitochondrial abnormalities found via muscle biopsy including: mitochondrial degeneration, [15] deletions of mitochondrial DNA, [16] [17] the reduction of mitochondrial activity [16] Increased urinary creatine excretion during relapses [18] Increased creatine kinase (postviral fatigue syndrome) Persistence of enteroviruses in muscle tissue [19] [20] [21] [22] Abnormalities of AMPK activation and glucose uptake in cultured skeletal muscle cells [23] [24] Reduced serum creatine kinase in people with severe ME