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Home Page Fibromyalgia; A Symptom Overview - Current Treatments - Drugs in Development Medication Research and Updates. Understanding & treating CFS & FM Leon Chaitow Validating Fibromyalgia By Dr. Clauw Medical Evaluation Form for Disability Claims. FMS Community Newsletter. It's Free! Subscribe Today. Fibrom-L. Online Support and
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Help OR Send payment to: Open Letter to Normals Workplace accommodations 7 Habits to gain Power in the Workplace Internet Radio Show for FM/CFIDS Meditation CD More Topics: Home Page Fibromyalgia; A Symptom Overview - Current Treatments - Drugs in Development Medication Research and Updates. Understanding & treating CFS & FM Leon Chaitow Validating Fibromyalgia By Dr. Clauw Medical Evaluation Form for Disability Claims. FMS Community Newsletter. It's Free! Subscribe Today. Fibrom-L. Online Support and
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Help OR Send payment to: Open Letter to Normals Workplace accommodations 7 Habits to gain Power in the Workplace Internet Radio Show for FM/CFIDS Meditation CD More Topics: Home Page Fibromyalgia; A Symptom Overview - Current Treatments - Drugs in Development Medication Research and Updates. Understanding & treating CFS & FM Leon Chaitow Validating Fibromyalgia By Dr. Clauw Medical Evaluation Form for Disability Claims. FMS Community Newsletter. It's Free! Subscribe Today. Fibrom-L. Online Support and
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Help OR Send payment to: Open Letter to Normals Workplace accommodations 7 Habits to gain Power in the Workplace Internet Radio Show for FM/CFIDS Meditation CD More Topics: Home Page Fibromyalgia; A Symptom Overview - Current Treatments - Drugs in Development Medication Research and Updates. Understanding & treating CFS & FM Leon Chaitow Validating Fibromyalgia By Dr. Clauw Medical Evaluation Form for Disability Claims. FMS Community Newsletter. It's Free! Subscribe Today. Fibrom-L. Online Support and
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Help OR Send payment to: Open Letter to Normals Workplace accommodations 7 Habits to gain Power in the Workplace Internet Radio Show for FM/CFIDS Meditation CD More Topics: Home Page Fibromyalgia; A Symptom Overview - Current Treatments - Drugs in Development Medication Research and Updates. Understanding & treating CFS & FM Leon Chaitow Validating Fibromyalgia By Dr. Clauw Medical Evaluation Form for Disability Claims. FMS Community Newsletter. It's Free! Subscribe Today. Fibrom-L. Online Support and
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Recommendations for Persons with Chronic Fatigue Syndrome (or Fibromyalgia) Who
Are Anticipating Surgery [This information was developed to reduce the risk of surgical procedures for ME/CFS/FM patients. It is evidence-based (see bibliography) and meant to be shared with the patient’s professional healthcare team. Dr. Charles Lapp, MD, directs the Hunter Hopkins Center for ME/CFS/FM in Charlotte, NC, and is co-author of a 2-hour online course on CFS Diagnosis and Management for healthcare professionals, developed with support from the CDC and CFIDS Association of America.] CFS is a disorder characterized by severe debilitating fatigue, recurrent flu-like symptoms, muscle pain, and neurocognitive dysfunction such as difficulties with memory, concentration, comprehension, recall, calculation and expression. A sleep disorder is not uncommon. All of these symptoms are aggravated by even minimal physical exertion or emotional stress, and relapses may occur spontaneously. Although mild immunological abnormalities (T-cell activation, low natural killer cell function, dysglobulinemias, and autoantibodies) are common in CFS, subjects are not immunocompromised and are no more susceptible to opportunistic infections than the general population. The disorder is not thought to be infectious, but it is not recommended that the blood or harvested tissues of patients be used in others. Intracellular magnesium and potassium depletion has been reported in CFS. For this reason, serum magnesium and potassium levels should be checked pre-operatively and these minerals replenished if borderline or low. Intracellular magnesium or potassium depletion could potentially lead to cardiac arrhythmias under anesthesia. Up to 97% of persons with CFS demonstrate vasovagal syncope (neurally mediated hypotension) on tilt table testing, and a majority of these can be shown to have low plasma volumes, low RBC mass, and venous pooling. Syncope may be precipitated by cathecholamines (epinephrine), sympathomimetics (isoproterenol), and vasodilators (nitric oxide, nitroglycerin, a-blockers, and hypotensive agents). Care should be taken to hydrate patients prior to surgery and to avoid drugs that stimulate neurogenic syncope or lower blood pressure. Allergic reactions are seen more commonly in persons with CFS than the general population. For this reason, histamine-releasing anesthetic agents (such as pentothal) and muscle relaxants (curare, Tracrium, and Mevacurium) are best avoided if possible. Propofol, midazolam, and fentanyl are generally well-tolerated. Most CFS patients are also extremely sensitive to sedative medications - including benzodiazepines, antihistamines, and psychotropics - which should be used sparingly and in small doses until the patient’s response can be assessed. Herbs and complementary and alternative therapies are frequently used by persons with CFS and FM. Patients should inform the anesthesiologist of any and all such therapies, and they are advised to withhold such treatments for at least a week prior to surgery, if possible. Of most concern are: Garlic, ginkgo, and ginseng (which increase bleeding by inhibiting platelet aggregation); Ephedra or ma huang (may cause hemodynamic instability, hypertension, tachycardia, or arrhythmia), Kava and valerian (increase sedation), St. John’s Wort (multiple pharmacological interactions due to induction of Cytochrome P450 enzymes), Echinacea (allergic reactions and possible immunosuppression with long term use). The American Society of Anesthesiologists recommends that all herbal medications be discontinued 2 to 3 weeks before an elective procedure. Stopping kava may trigger withdrawal, so this herbal (also known as awa, kawa, and intoxicating pepper) should be tapered over 2 to 3 days. Finally, HPGA Axis Suppression is almost universally present in persons with CFS, but rarely suppresses cortisol production enough to be problematic. Seriously ill patients might be screened, however, with a 24-hour urine free cortisol level (spot or random specimens are usually normal) or Cortrosyn stimulation test, and provided cortisol supplementation if warranted. Those patients who are being supplemented with cortisol should have their doses doubled or tripled before and after surgery. Summary Recommendations 1. Ensure that serum magnesium and potassium levels are adequate. 2. Hydrate the patient prior to surgery. 3. Use catecholamines, sympathomimetics, vasodilators, and hypotensive agents with caution. 4. Avoid histamine-releasing anesthetic and muscle-relaxing agents if possible. 5. Use sedating drugs sparingly. 6. Ask about herbs and supplements, and advise patients to taper off such therapies at least one week before surgery. 7. Consider cortisol supplementation in patients who are chronically on steroid medications or who are seriously ill. 8. Relapses are not uncommon following major operative procedures, and healing is said to be slow but there are no data to support this contention. * * * * I hope that you have found these comments useful, and that they will serve to reduce the risk of surgical procedures. Yours truly,
Hypoglycemia
(low blood sugar)a problem for many Chronic Fatigue Syndrome and Fibromyalgia patients,
but treatable. "My experience is that chronic hypoglycemia is a very common cause of fatigue in CFS sufferers," writes Dr. Sarah Myhill, MD, a UK-based CFS specialist focused on nutrition, preventive medicine, and patient education. This article is excerpted from Dr. Myhill’s book – Diagnosing and Treating Chronic Fatigue Syndrome – available in pdf format at her website (DrMyhill.co.uk).* It reflects her experience treating more than 4,000 patients with CFS over the past 20 years - many of whom also have Fibromyalgia. It is critically important for the body to maintain blood sugar levels within a narrow range. If the blood sugar level falls too low, energy supply to all tissues, particularly the brain, is impaired. However, if blood sugar levels rise too high this is very damaging to arteries and the long term effect of arterial disease is heart disease and strokes – this is probably caused by a local reaction in periarteriolar fat [fat around the tiny arteries called arterioles], resulting in release of proinflammatory cytokines causing damage to arteries. [Proinflammatory cytokines are signaling chemicals involved in amplifying inflammatory reactions.] Normally the liver controls blood sugar levels. It makes the sugar from energy stores inside the liver and releases sugar into the blood stream minute by minute in a carefully regulated way to cope with body demands, which may fluctuate from minute to minute. This system of control works perfectly well until we upset it by eating the wrong thing. Eating excessive sugar at one meal, or excessive refined carbohydrate, which is rapidly digested into sugar, can suddenly overwhelm the liver’s normal control of blood sugar levels. We evolved over millions of years eating a diet that was very low in sugar and had no refined carbohydrate. Control of blood sugar therefore largely occurred as a result of eating this Stone Age diet and the fact that we were exercising vigorously, so any excessive sugar in the blood was quickly burned off. Nowadays the situation is different - we eat large amounts of sugar and refined carbohydrate and do not exercise enough in order to burn off this excessive sugar. The body therefore has to cope with this excessive sugar load by other mechanisms. When food is digested, the sugars and other digestive products go straight from the gut in the portal veins to the liver, where they should all be mopped up by the liver and processed accordingly. Excessive sugar or refined carbohydrate overwhelms the liver, which simply cannot mop up the amount of sugar which is there and the sugar spills over into the systemic circulation. This results in high blood sugar, which is extremely damaging to arteries. If one were exercising hard, this would be quickly burned off. However, if one is not, then other mechanisms of control are brought into play. The key player here is insulin, a hormone excreted by the pancreas. This is very good at bringing blood sugar levels down and it does so by shunting the sugar into fat. There is then a rebound effect and blood sugars may well go too low. Low blood sugar is also dangerous to the body because the energy supplied to all tissues is impaired. It is when the blood sugar is low that this is called hypoglycemia. Subconsciously, people quickly work out that eating more sugar alleviates these symptoms, but of course they invariably overdo things, the blood sugar level then goes high, and one ends up on a rollercoaster ride of blood sugar going up and down throughout the day. SYMPTOMS OF HYPOGLYCEMIA The problem is that when the blood sugar is high people feel “normal,” indeed maybe slightly boosted by this high level of blood sugar. This is because they have good energy supply to their muscles and brain, albeit short-term. The problem arises when blood sugar levels dive as a result of insulin being released and energy supply to the brain and the body is suddenly impaired. This results in a whole host of symptoms. The brain symptoms include: The body symptoms include: The sufferer may look as if they are about to faint (and indeed often do) and have to sit down and rest. The symptoms can be quickly alleviated by eating something sweet - if nothing is done then the sufferer gradually recovers. These symptoms of hypoglycemia can be brought on by missing a meal (or one’s usual sweet snack top up such as a sweet drink), by vigorous exercise or by alcohol. Diabetics may become hypoglycemic if they use too much medication. When blood glucose levels fall for any reason, glycogen stores in the liver may be mobilized to prop them up. The trouble is that these are probably already rather poor in people with increased carbohydrate intake, where insulin is relied on heavily. Another rapid and very effective way in which the body repletes the low glucose is by hepatic [liver] conversion of short chain fatty acids to glucose. In a healthy person on a good balanced diet the only time this is of importance is during the night because of the long break between food intake. Short chain fatty acids are then used to prop up circulating glucose and prevent a fall below whatever that person’s usual fasting glucose level is. Short chain fatty acids are made in the gut by bacteria fermenting fiber (and such starch as escapes small intestinal digestion). Production is maximized from about 3 hours after food intake. That is to say, short chain fatty acids are highly protective against the dips we see in blood sugar. [As indicated below, they have no effect on blood sugar and are the preferred fuel of the cells’ energy producing mitochondria.] Therefore, a key symptom of a hypoglycemic tendency is disturbed sleep. This occurs typically at 2 or 3 a.m., when blood sugar levels fall and there are insufficient short chain fatty acids to maintain a blood sugar. Low blood sugar is potentially serious to the brain, which can only survive on sugar and, therefore, there is an adrenalin reaction to bring the blood sugar back, but this wakes the sleeper up at the same time. TEST FOR HYPOGLYCEMIA Measuring blood sugar levels is not a terribly useful test for hypoglycemia, partly because they fluctuate so much and partly because by the time one gets the symptoms of hypoglycemia, the blood sugar levels have started to correct. A much better test would be to measure short chain fatty acids in blood collected in the morning before breakfast. The test should be done as follows: It is important to continue your usual diet – indeed, there are no special dietary instructions for the test, but the blood sample must be taken between 9 and 12 hours after a meal.... There is a final twist to the hypoglycemic tale which complicates the situation further. When one becomes stressed for whatever reason, one releases stress hormones in order to allow one to cope with that stress. Insulin is such a stress hormone and has the effect of shunting sugar in the blood stream into cells. This produces a drop in blood sugar levels and also causes hypoglycemia. Therefore, hypoglycemia can be both a cause of stress and the result of stress, indeed, another one of those vicious cycles that are so often seen in disease states. TREATMENT OF HYPOGLYCEMIA Treatment is to avoid all foods containing sugar and refined carbohydrate. The problem for the established hypoglycemic is that it may take many weeks or indeed months for the liver to regain full control of blood sugar, and therefore the symptoms of hypoglycemia may persist for some time whilst the sufferer continues to avoid sugar and refined carbohydrate. This means that when you change your diet you will get withdrawal symptoms and it may take many weeks of a correct diet before these symptoms resolve. This type of addiction is very much like that which the smoker or the heavy drinker suffers from. One needs to switch to a diet which concentrates on eating proteins, fats, and complex (and therefore slowly digested) carbohydrates. Initially I suggest doing a high protein high fat diet, but include all vegetables (care with potato), nuts, seeds, etc. Fruit is permitted but rationed, since excessive amount of fruit juices or dried fruits contain too much fruit sugar for the liver to be able to deal with. I suggest one piece of fruit at mealtimes. I now consider taking high dose probiotics an essential part of controlling low blood sugar. [Probiotics are dietary supplements containing potentially beneficial bacterial cultures intended to assist the body’s naturally occurring gut flora to reestablish themselves.] This is because probiotics ferment carbohydrates to short chain fatty acids – these have no effect on blood sugar and are the preferred fuel of mitochondria. The best and cheapest way to do this is to brew your own – see section on probiotics. Probiotics also displace yeast, which worsens the hypoglycemia problem. With time the regime can be relaxed, but a return to excessive sugar and refined carbohydrate means the problem starts again. Finally, many sufferers of hypoglycemia may need something sweet to eat immediately before and during vigorous exercise, until the body learns to fully adapt. Hypoglycemia is usually accompanied by micronutrient deficiencies. You should also take nutritional supplements. My experience is that chronic hypoglycemia is a very common cause of fatigue in CFS sufferers. To tackle hypoglycemia one needs to do a diet based on foods of low glycemic index (GI). The GI is a measure of the ability of foods to raise one’s blood sugar levels. Sugar (that is, disaccharides) have arbitrarily been given a GI of 100. High GI foods are the grains (wheat, rye, oats rice etc), root vegetables (potato, sweet potato, yam, parsnip), alcohol, sugars, and fruits, dried fruits and fruit juices. But expect to see withdrawal symptoms which can persist for weeks. [For more detailed lists of foods with no carbohydrate content and with low, medium, and high GI measures (which also depend on quantity consumed), see "Low Glycemic Index Diet - What to Eat On It" at |
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