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Seems I'm always asking for Purrs...

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jmcquown - 02 Feb 2005 18:46 GMT
Sorry, but here we go again.  Tomorrow at 12:30 I have an appointment set up
by the Social Security Disability folks for a medical exam.  They called
last week and told me to expect the paperwork in the mail.  I got the
paperwork and was mildly surprised to find the exam is not for my IBS or
depression - it's for arthritis.  Now, I never claimed to have clinically
diagnosed arthritis.  But I mentioned to the local case worker I take
aspirin a couple of times a day due to aches in my arms.  She apparently
noted this in my paperwork before sending it off to the state capitol.  I
reiterated to the new case worker in Nashville I have NOT been diagnosed
with arthritis.  But she's sending me off tomorrow to get X-rays to
determine whether or not I have arthritis.  (I don't know; maybe it's just
normal to have your arms ache when you're middle aged.)

I can only surmise (probably a bad idea) they took the medical records my
regular doctor sent at face value since they (so far) aren't sending me to
anyone to evaluate those claims.  Oh, and I got a travel voucher; they
calculated the mileage and will reimburse me $11.20 USD after I see the
doctor.

Anyway, any spare purrs for my visit tomorrow would be appreciated.

OB Cats:  Persia successfully killed another paper bag this morning.  It was
apparently full of greeblings :)

Jill
Signature

I used to have a handle on life...but it broke off.

Holly - 02 Feb 2005 18:54 GMT
Purrs from my crew that everything turns out in your favor.
Holly, Pheniox, Sasha and Isabella (who has finally been accepted)
Jo Firey - 02 Feb 2005 19:13 GMT
Problems in your neck could very well make your arms hurt.  And if you have
IBS it might be that you have other autoimmune problems such as some form of
Inflammatory arthritis.

This won't necessarily be the only exam they send you for.  I had two.  One
for depression and another for arthritis.  Deaf they took my word (or my
doctors word) for.

They will sometimes approve disability for a combination of problems where
they would not for any one problem by itself.  They also look into your
occupation, your work history and consider your age.

Jo

> Sorry, but here we go again.  Tomorrow at 12:30 I have an appointment set
> up
[quoted text clipped - 23 lines]
>
> Jill
jmcquown - 02 Feb 2005 19:30 GMT
> Problems in your neck could very well make your arms hurt.  And if
> you have IBS it might be that you have other autoimmune problems such
> as some form of Inflammatory arthritis.

I've had pains in my left neck & shoulder which I initially attributed to
sleeping in a weird position.  But I surely can't be sleeping that way all
the time?  Heat helps with it; those Thermacare patches are nice.  I've also
(lately) had pressure in my chest.  It is my understanding heart related
problems in women often manifest themselves in neck & shoulder pain - oh
joy.

John is very worried about this; he had bypass surgery last year and is
upset to hear about my feeling pressure in my chest and pain in my arms and
shoulder.  What's a body to do?  I'm under a lot of stress; bills due and no
income or good job prospects. (sigh)

> This won't necessarily be the only exam they send you for.  I had
> two.  One for depression and another for arthritis.  Deaf they took
> my word (or my doctors word) for.

I'm sure they'll send me for another.  But when I filed (back in October)
the notification on the web site indicated they would have to make a
determination by 3/5.  So they are running out of time... or I am.

> They will sometimes approve disability for a combination of problems
> where they would not for any one problem by itself.  They also look
[quoted text clipped - 32 lines]
>> --
>> I used to have a handle on life...but it broke off.
Monique Y. Mudama - 02 Feb 2005 21:07 GMT
>> Problems in your neck could very well make your arms hurt.  And if you have
>> IBS it might be that you have other autoimmune problems such as some form
[quoted text clipped - 6 lines]
> problems in women often manifest themselves in neck & shoulder pain - oh
> joy.

I have posture problems, and my chiro recommended one of those weird memory
foam pillows for me.  My lower back hurt the first few nights, but since then
I'm pretty happy with it.  It encourages my neck to curve properly
(apparently, I somehow developed the habit of keeping my neck straight, so my
spine curves too much to accomodate).  Anyway, the reason I mention this is,
whether I sleep on my side or my back, the pillow seems to discourage really
bizarre sleeping positions.  Maybe something like this could help?  I hate to
suggest it, as it costs money and I have no idea if it would actually help.

Signature

monique, roommate of Oscar the (female) grouch
~~~~~~~~~~~~~~~~~~
Eros was adopted!  Eros has a home now!  *cheer!*

jmcquown - 02 Feb 2005 22:27 GMT
>>> Problems in your neck could very well make your arms hurt.  And if
>>> you have IBS it might be that you have other autoimmune problems
[quoted text clipped - 16 lines]
> positions.  Maybe something like this could help?  I hate to suggest
> it, as it costs money and I have no idea if it would actually help.

Hey, I'm open to any and all suggestions :)  Thank you for your thoughts on
the matter.  (I use a feather pillow which I tend to bunch around my neck in
a sort of U shape for supporting my neck.)

Jill
Howard Berkowitz - 03 Feb 2005 02:32 GMT
> I have posture problems, and my chiro recommended one of those weird
> memory
[quoted text clipped - 11 lines]
> suggest it, as it costs money and I have no idea if it would actually
> help.

To put things on topic, and to give the purrs, I have a certain degree
of feline enforcement of sleeping positions. I tend to lie on my side,
which is probably best for me. That will get Mr. Clark on my hip or a
little above. A 17 pound heating pad does get achy, but if I lie on my
back, I will get a massage and bath.  If, however, I roll onto my
stomach, it is understood that my back belongs to Ding.
Steve Touchstone - 03 Feb 2005 09:29 GMT
>I have posture problems, and my chiro recommended one of those weird memory
>foam pillows for me.  My lower back hurt the first few nights, but since then
[quoted text clipped - 4 lines]
>bizarre sleeping positions.  Maybe something like this could help?  I hate to
>suggest it, as it costs money and I have no idea if it would actually help.

My mom got one of those pillows for my Dad. He initially resisted
using it, but now he wouldn't be without it. In fact it's very well
travelled, as they've taken it to Europe and on a couple cruises.

Also, adding purrs that things work out with your claim. Sometimes it
seems like they have a script they follow to delay claims as long as
possible.
Signature

Steve Touchstone,
faithful servant of Sammy and Little Bit

stouchst@JUNKsirinet.net [remove Junk for email]
Home Page: http://www.sirinet.net/~stouchst/index.html
Cat Pix: http://www.sirinet.net/~stouchst/animals.html

Monique Y. Mudama - 03 Feb 2005 17:48 GMT
>>I have posture problems, and my chiro recommended one of those weird memory
>>foam pillows for me.  My lower back hurt the first few nights, but since
[quoted text clipped - 12 lines]
> Also, adding purrs that things work out with your claim. Sometimes it seems
> like they have a script they follow to delay claims as long as possible.

Not my claim!  CatNipped's!  I just have the pillow ...

Signature

monique, roommate of Oscar the (female) grouch
~~~~~~~~~~~~~~~~~~
Eros was adopted!  Eros has a home now!  *cheer!*

Treeline - 03 Feb 2005 01:27 GMT
> I've had pains in my left neck & shoulder which I initially attributed to
> sleeping in a weird position.  But I surely can't be sleeping that way all
> the time?  Heat helps with it; those Thermacare patches are nice.  I've also
> (lately) had pressure in my chest.  It is my understanding heart related
> problems in women often manifest themselves in neck & shoulder pain - oh
> joy.

After you get your disability, you can get a prescription or the PT person can
give you something that looks like a small bedroll. You put it in the pillow
and forms a sort of little log for the neck for those with neck problems. It's
paid for by PT or physical therapy and runs around $20. I got one and it works
although it sometimes rolls around in my pillow. Keep your neck nice and
parallel when sleeping.

There is now a common Fast CT Scan. It's somewhat cheap and covered by
insurance. It's a cheap and easy way to find out if your arteries are
calcified. It WILL NOT detect soft deposits. It will detect hardening of the
arteries by zeroing in on the calcium deposits. It's several hundred dollars
but your insurance should cover it when you get insurance, assuming you do not
have any for the moment.

The neck and shoulder pain might be the complex called fibromyalgia or chronic
fatigue syndrome. This can be diagnosed by a series of tender spots on the
shoulder and neck area. It's also associated with depression. The spots are on
the upper back and with a light sleep pattern, I'll bet this is something that
might be a cause for you. Granted this gets a lot of bad press as an illness.

One common, well should be common treatment, are extremely low dosages of
SSRI's, about 1/4 the usual dosage. The point is to get someone undepressed
enough so they can get some normal sleep, the deep sleep of delta waves. Often
the people are not getting deep sleep and that leads to the aches and pains and
even I would guess IBS. This can be diagnosed by sleep EEGs but that's well,
well. Anyway, it's a very light dosage, 1/4th the normal dosage for the SSRI's
(selective serotonin reuptake inhibitors). Since 1/4th, well tolerated, just
enough to smooth you out during sleep and during the day.

Inositol can achieve what SSRI's do and it's available in health food stores.
But it's the same price as a prescription for SSRI's (Zoloft Paxil Prozac). A
natural product, really derived from the B vitamins. It will perk you up.
Couple tablespoons in orange juice. Au naturel. It's in the medical literature.
I am not making this up although it's not widely known for some reason.
Meroowwrr.

I am not a doctor. Nor do I play one in the streets. But I read the literature
and have correctly diagnosed people which is then confirmed by their lazy
doctors! Usually in person. Doing this over the internet is a bit silly but I
was concerned about your going for disability which can be a super hassle
depending on where you live.

Oh, if you get any static, see a lawyer. Going to the formal hearing without a
lawyer is probably a big-time no-no from what I hear. I don't know how this
works but a lawyer will step in when the administrative person tries to trip
you up with tricky questions to make you look bad. And that's very easy to do
without a lawyer to say, you don't have to answer that...
Howard Berkowitz - 03 Feb 2005 02:59 GMT
> > I've had pains in my left neck & shoulder which I initially attributed
> > to
[quoted text clipped - 42 lines]
> One common, well should be common treatment, are extremely low dosages of
> SSRI's, about 1/4 the usual dosage.

Ummm...are you sure you are thinking SSRI's?  Most "typical" SSRIs do
not have any effect on chronic pain. What is often effective for chronic
pain, fibromyalgia, and sometime migraine prevention is a low-dose, as
you suggest, tricyclic antidepressant [TCA] (e.g., amitriptyline 10-25mg
at bedtime, where the starting psychiatric dosage is about 75mg).  

TCAs are sometimes called "first generation" and SSRIs "second
generation", but that's misleading. There are other classes of the same
vintage as TCAs (monoamine oxidase inhibitors, or MAOI). [1 for some
explanation]

>The point is to get someone
> undepressed
> enough so they can get some normal sleep, the deep sleep of delta waves.

Usually, the improvement in sleep, chronic pain, and fibromyalgia with
TCAs is attributed to other than an antidepressant activity -- but it's
even less understood than the antidepressant effect.  One of the key
things about the use of TCAs in these conditions is that if they work,
they tend to work within a few days, where it typically takes 3 weeks or
so for them to affect depression. The working hypothesis is that in the
first usage, the TCAs make more neurotransmitters (principally
serotonin) available in the tissues outside the brain, where the
continued dosage is necessary to reset a brain chemical level in
depression.  Other suggestive evidence is that cyclobenzaprine
(Flexeril) is the first-line drug for fibromyalgia.  While it's
chemically related to the TCAs, it has no antidepressant activity -- but
it is known to increase serotonin levels in muscle tissue.  TCAs are
"nonselective" in comparison to SSRIs, as they increase both serotonin
and norepinephrine levels.

Without getting into the biochemistry (although I will comment on that
below), the original idea of SSRIs -- blocking the reuptake of
neurotransmitters from the sending neuron, so they can act longer on the
receiving neuron -- has generalized. There are reuptake inbibitors that
increase both serotonin and norepinephrine, serotonin only, or
norepinephrine only.  A new dual reuptake inhibitor, duloxetine
(Cymbalta) is the first reuptake inhibitor approved for pain syndromes,
specifically for diabetic neuropathy.

> Often
> the people are not getting deep sleep and that leads to the aches and
[quoted text clipped - 16 lines]
> I am not making this up although it's not widely known for some reason.
> Meroowwrr.

I'm just not familiar with it.

> I am not a doctor. Nor do I play one in the streets. But I read the
> literature
> and have correctly diagnosed people which is then confirmed by their lazy
> doctors!

Fair enough. I just simulate them in software. :-)

>Usually in person. Doing this over the internet is a bit silly
> but I
> was concerned about your going for disability which can be a super hassle
> depending on where you live.

[1] Quickie course in the biochemistry of most antidepressants.

Depression appears to be related to low effective levels, in the brain,
of one or both of two neurotransmitters, serotonin and norepinephrine.  
Most of you probably know that nerve-to-nerve transmission is more
chemical than electrical, although it's more electrical with respect to
when one cell "fires".

Picture a hollow gap between the sending neuron and the receiving
neuron. This gap is called the synapse. The sending neuron doesn't just
send a quick burst -- the chemical transmitters stay in the gap for a
period of time. The longer they are present, the more they are absorbed
by the receiving cell. The receiving cell will eventually convert them
to waste products, but the longer they act on the receiving cell, the
greater the effect.

TCAs inhibit one enzyme, COMT [2], in the receiving cell, which breaks
down both serotonin and norepinephrine.  COMT isn't the only enzyme
involved; MAO [4] is another enzyme in the breakdown chain.  MAO
inhibitors slow postsynaptic (receiving) breakdown in a different way
than TCAs. MAO inhibitors, while clinically effective, aren't used much
because they can interact with a wide (and weird) range of foods and
drugs (including TCAs) to cause fatally high blood pressure.

Back to the sending/presynaptic cell. This cell keeps track of how much
neurotransmitter it pumps into the synapse, and, when it decides it's
sent enough, it sucks it back up (reuptake). Reuptake inhibitors slow
this process and keep the transmitter in the synapse longer.

So, the different classes of antidepressants all raise the effective
duration of neurotransmitters in the receiving neuron. TCAs and MAOIs do
it in the receiver, while reuptake inhibitors do it to the sender.

[2]  Do you really, really want to know what COMT stands for? I warned
    you... [3]

[3] Catechol-O-methyl transferase.

[4] MAO is monoamine oxidase. MAO inhibitors interact with foods rich
   in a chemical called tyramine. The most important of these foods,
   clearly, is chocolate [5]. Aged cheeses, smoked fish, and Chianti
   (but not so much other red wines) also have a lot.

[5] Chocolate also contains phenylethylalanine, which has been
   thought to be a mood elevator, sexual stimulant, or both --
   in women.
Treeline - 03 Feb 2005 03:30 GMT
> > > I've had pains in my left neck & shoulder which I initially attributed
> > > to
[quoted text clipped - 48 lines]
> you suggest, tricyclic antidepressant [TCA] (e.g., amitriptyline 10-25mg
> at bedtime, where the starting psychiatric dosage is about 75mg).

Thanks for your input. It's been a few years since I heard this discussed by a
Hahvad doc specializing in this on an interview on NPR. Sounds as though you
know more about this than I do. I can't find my notes now. I block out the
antidepressant you mentioned since when combined with an MAO can cause strokes,
but that's ancient history now. But it's in the literature now what type of
anti-depressant to take. Thanks again for your correction.

> TCAs are sometimes called "first generation" and SSRIs "second
> generation", but that's misleading. There are other classes of the same
[quoted text clipped - 111 lines]
>     thought to be a mood elevator, sexual stimulant, or both --
>     in women.
Howard Berkowitz - 03 Feb 2005 04:33 GMT
> Thanks for your input. It's been a few years since I heard this discussed
> by a
[quoted text clipped - 3 lines]
> the
> antidepressant

Pretty much ANY antidepressant, including chocolate.

>you mentioned since when combined with an MAO can cause
> strokes,
> but that's ancient history now. But it's in the literature now what type
> of
> anti-depressant to take. Thanks again for your correction.

This is probably far too much information, but I'll paste the
information from Medscape's database. This class of drug, which still
has applications although never the first choice, has one of the widest
range of bad interactions of ANY class of medication.  You need to have
about a two-week period between the last dose of any other
antidepressant I can think of, and the first dose of MAOI:

Concomitant use of MAO inhibitors and certain food or prescription or
nonprescription (over-the-counter, OTC) drugs can result in interactions
that have the potential to cause hypertensive crisis due to the release
and potentiation of catecholamines similar to that experienced in
pheochromocytoma. The severity and consequences of such interactions
vary among individuals. If only minor increases in blood pressure occur,
patients may be unaware of the interactions. However, if substantial and
rapid increases in blood pressure (an increase of 30 mm Hg or more in
systolic blood pressure within 20 minutes) occur, patients may
experience symptoms associated with subarachnoid hemorrhage or cardiac
failure (sudden severe occipital headache, palpitations) if the cerebral
vasculature or cardiac musculature are already weakened. (See
Hypertensive Crisis under Cautions: Cardiovascular Effects.)

Food

Hypertensive crises have occurred following ingestion of foods
containing large amounts of tyramine or tryptophan in some patients
receiving MAO inhibitors. In general, patients should avoid protein
foods that have undergone protein breakdown by aging, fermentation,
pickling, smoking, or bacterial contamination; protein extracts and
liquid or powdered dietary supplements also should be avoided. Patients
should be specifically instructed not to eat foods such as cheese,
particularly strong or aged varieties (e.g., cheddar, Camembert,
Stilton) and processed cheese; sour cream; wine, especially chianti,
champagne, and alcohol-free or reduced-alcohol wine products; beer,
including alcohol-free and reduced-alcohol beers; pickled herring;
anchovies; caviar; shrimp paste; liver, especially chicken liver; dry
sausage (e.g., Genoa salami, hard salami, pepperoni, Lebanon bologna);
figs, particularly if overripe, or canned figs; raisins; bananas or
avocados, particularly if overripe; chocolate; soy sauce; bean curd;
yeast extracts (including brewer?s yeast in large quantities); yogurt;
papaya products, including certain meat tenderizers; and pods of broad
beans (e.g., fava beans). Excessive amounts of caffeine may also
reportedly precipitate hypertensive crisis. Specialized references on
food constituents or a dietician should be consulted for more specific
information on the tyramine content of foods and beverages.

Sympathomimetic Agents and Catecholamine-releasing Agents

Because some patients appear to be particularly sensitive to the
hypertensive effects of sympathomimetic agents during MAO inhibitor
therapy, centrally acting sympathomimetic agents (e.g., amphetamines) or
peripherally acting sympathomimetic agents, including prescription or
nonprescription cold, hay fever, or weight-reducing preparations that
contain pressor agents (e.g., ephedrine, phenylpropanolamine), should
not be administered concomitantly with an MAO inhibitor.

Parenteral or oral administration of reserpine or guanethidine in
patients receiving MAO inhibitors may cause a severe pressor response as
a result of a sudden release of accumulated catecholamines. Therefore,
the manufacturers of MAO inhibitors do not recommend concomitant use of
guanethidine in patients receiving an MAO inhibitor and also recommend
that reserpine be administered cautiously in patients receiving MAO
inhibitors.

Levodopa and other Catecholamines

Hypertension, headache, hyperexcitability, and related symptoms
reportedly have occurred in patients receiving MAO inhibitors
concurrently with methyldopa, dopamine, or levodopa. It has been
suggested that use of a decarboxylase inhibitor (e.g., carbidopa) with
levodopa may prevent hypertensive reactions during concomitant therapy
with an MAO inhibitor.

?Drugs Associated with Serotonin Syndrome

Serotonin syndrome may occur in patients receiving MAO inhibitors in
combination with other serotonergic drugs. Although the syndrome appears
to be relatively uncommon and usually mild in severity, serious
complications, including seizures, disseminated intravascular
coagulation, respiratory failure, severe hyperthermia, and death
occasionally have been reported. The precise mechanism of the syndrome
is not fully understood; however, it appears to result from excessive
serotonergic activity in the CNS, probably mediated by activation of
serotonin 5-HT1A receptors. The possible involvement of dopamine and
5-HT2-receptors also has been suggested, although their roles remain
unclear.

The syndrome most commonly occurs when 2 or more serotonergic agents
with different mechanisms of action are administered either concurrently
or in close succession. Serotonergic agents include those that increase
serotonin synthesis (e.g., the serotonin precursor tryptophan),
stimulate synaptic serotonin release (e.g., some amphetamines,
dexfenfluramine [no longer commercially available in the US],
fenfluramine [no longer commercially available in the US]), inhibit the
reuptake of serotonin after release (e.g., selective serotonin-reuptake
inhibitors [SSRIs], tricyclic antidepressants, trazodone,
dextromethorphan, meperidine, tramadol), decrease the metabolism of
serotonin (e.g., MAO inhibitors), have direct serotonin postsynaptic
receptor activity (e.g., buspirone), or nonspecifically induce increases
in serotonergic neuronal activity (e.g., lithium salts).

The combination of MAO inhibitors and SSRI antidepressants (e.g.,
fluoxetine) appears to be responsible for most of the recent case
reports of serotonin syndrome. The syndrome also has been reported when
MAO inhibitors have been combined with tricyclic antidepressants,
tryptophan, meperidine, or dextromethorphan. In rare cases, serotonin
syndrome reportedly has occurred with the recommended dosage of a single
serotonergic agent (e.g., clomipramine) or during accidental overdosage
(e.g., sertraline intoxication in a child). Some other drugs that have
been implicated in certain circumstances include buspirone,
bromocriptine, dextropropoxyphene, methylenedioxymethamphetamine (MDMA;
??ecstasy??), and selegiline (a selective MAO-B inhibitor). Other drugs
that have been associated with the syndrome but for which less
convincing data are available include carbamazepine, fentanyl, and
pentazocine.

Clinicians should be aware of the potential for serious, possibly fatal
reactions associated with serotonin syndrome in patients receiving 2 or
more drugs that increase the availability of serotonin in the CNS, even
if no such interactions with the specific drugs have been reported to
date in the medical literature. Pending further data, all drugs with
serotonergic activity should be used cautiously in combination and such
combinations avoided whenever clinically possible. Some clinicians state
that patients who have experienced serotonin syndrome may be at higher
risk for recurrence of the syndrome upon reinitiation of serotonergic
drugs. Pending further experience in such cases, some clinicians
recommend that therapy with serotonergic agents be limited following
recovery. In cases in which the potential benefit of the drug is thought
to outweigh the risk of serotonin syndrome, lower potency agents and
reduced dosages should be used, combination serotonergic therapy should
be avoided, and patients should be monitored carefully for symptoms of
serotonin syndrome. For further information on serotonin syndrome,
including manifestations and treatment, see Serotonin Syndrome under
Drug Interactions: Drugs Associated with Serotonin Syndrome, in
Fluoxetine Hydrochloride 28:16.04.20.

Selective Serotonin-reuptake Inhibitors

Concurrent use of selective serotonin-reuptake inhibitors (SSRIs) and
MAO inhibitors potentially is hazardous and may result in serotonin
syndrome. Probably because of its extensive clinical use and the
prolonged elimination half-life of both fluoxetine and norfluoxetine,
fluoxetine has been the SSRI most commonly implicated in serotonin
syndrome when combined with MAO inhibitor therapy. In at least 2 cases,
serotonin syndrome has developed when MAO inhibitor therapy has been
initiated after the discontinuance of fluoxetine therapy. Shivering,
diplopia, nausea, confusion, and anxiety reportedly occurred in one
patient 6 days after discontinuance of fluoxetine therapy and 4 days
after initiation of tranylcypromine therapy; signs and symptoms resolved
without apparent sequelae within 24 hours following discontinuance of
the MAO inhibitor in this patient. In another case, the initiation of
tranylcypromine therapy more than 5 weeks after discontinuance of
fluoxetine reportedly resulted in serotonin syndrome. The manufacturer
of fluoxetine, the manufacturers of MAO inhibitors, and some clinicians
state that concurrent administration of fluoxetine and MAO inhibitors is
contraindicated. Because both fluoxetine and its principal metabolite
have relatively long half-lives, the manufacturer of fluoxetine, the
manufacturers of MAO inhibitors, and some clinicians recommend that at
least 5 weeks elapse between discontinuance of fluoxetine therapy and
initiation of MAO inhibitor therapy, since administration of an MAO
inhibitor prior to elapse of this time may increase the risk of serious
adverse effects. Although the manufacturers of some MAO inhibitors
(i.e., phenelzine) recommend that at least 10 days elapse following
discontinuance of MAO inhibitor therapy prior to initiation of
fluoxetine therapy, based on clinical experience with concurrent
administration of tricyclic antidepressants and MAO inhibitors, the
manufacturers of fluoxetine and the manufacturers of some MAO inhibitors
(e.g., selegiline, tranylcypromine) recommend that at least 2 weeks
elapse following discontinuance of an MAO inhibitor prior to initiation
of fluoxetine therapy.

Other SSRI antidepressants, including sertraline and citalopram, also
have been associated with serotonin syndrome when given in combination
with MAO inhibitors. Because of the potential risk of serotonin syndrome
when SSRIs are combined with MAO inhibitor therapy, the manufacturers of
fluvoxamine, paroxetine, and sertraline currently recommend that a
drug-free interval of at least 2 weeks elapse when switching from an MAO
inhibitor to these agents or when switching from these agents to an MAO
inhibitor.

Moclobemide, a selective and reversible MAO-A inhibitor (not
commercially available in the US), also has been associated with
serotonin syndrome and such reactions have been fatal in several cases
in which the drug was given in combination with citalopram or with
clomipramine. Pending further experience with such combinations, some
clinicians recommend that concurrent therapy with moclobemide and SSRIs
be used only with extreme caution and that the SSRI should have been
discontinued for some time (depending on the elimination half-lives of
the drug and its active metabolites) before initiating moclobemide
therapy.

Tryptophan

Although tryptophan sometimes has been used to enhance the
antidepressant activity of MAO inhibitors, serotonin syndrome, which was
fatal in at least one case, has been reported in a limited number of
patients receiving these drugs in combination either with or without
concurrent lithium therapy. While the mechanism for this interaction has
not been fully elucidated, it has been suggested that these adverse
effects resemble serotonin syndrome and therefore may result from a
marked increase in serotonin availability in the CNS when these agents
are administered concurrently. Behavioral and neurologic syndromes,
including disorientation, confusion, amnesia, delirium, agitation,
hypomanic signs, ataxia, myoclonus, hyperreflexia, shivering, ocular
oscillations, and Babinski signs, also have been reported in patients
receiving MAO inhibitors and tryptophan concomitantly. Pending further
evaluation of this potential interaction, clinicians should be aware
that toxic reactions may occur when MAO inhibitors and tryptophan are
administered concomitantly.

Buspirone

Elevations in blood pressure have been observed in several patients
receiving an MAO inhibitor and buspirone concomitantly; no adverse
sequelae were associated with these elevations. Buspirone may have been
partially responsible for a case of serotonin syndrome that resulted in
the death of a patient receiving buspirone, an MAO inhibitor
(tranylcypromine), and fluoxetine concomitantly. Pending accumulation of
additional data, it is recommended that MAO inhibitors not be used
concomitantly with buspirone. Some manufacturers recommend that at least
10 days elapse between discontinuance of MAO inhibitor therapy and
administration of buspirone.

?Tricyclic Antidepressants

Concomitant administration of MAO inhibitors and tricyclic
antidepressants is contraindicated, and it generally is recommended that
at least 2 weeks should elapse between discontinuance of tricyclic
antidepressant therapy or MAO inhibitor therapy and initiation of
therapy with the other class of drugs. Serious, sometimes fatal,
reactions including hyperpyrexia, confusion, diaphoresis, myoclonus,
rigidity, seizures, cardiovascular disturbances, and coma have occurred
in patients who received an MAO inhibitor and a tricyclic antidepressant
concomitantly. Patients receiving therapeutic dosages of an oral MAO
inhibitor and an oral tricyclic antidepressant concomitantly generally
have experienced nonfatal hyperpyrexia, hypertension, tachycardia,
confusion, and seizures; most reported cases of hyperpyretic crises,
severe seizures, or death occurred following overdosage or parenteral
administration of one or both drugs. Although the mechanism has not been
clearly established, these reactions resemble serotonin syndrome and may
be caused by excessive serotonergic activity in CNS. (See Drug
Interactions: Drugs Associated with Serotonin Syndrome.)

?CNS Depressants

Several manufacturers caution that MAO inhibitors may be additive with,
or may potentiate the action of, CNS depressants such as opiates or
other analgesics, barbiturates or other sedatives, anesthetics, or
alcohol. CNS depressants should be administered cautiously to patients
receiving MAO inhibitors in order to avoid excessive sedation and acute
hypotension; a reduction in dosage of the CNS depressant agent(s) may be
necessary. One manufacturer recommends that, if emergency surgery is
necessary in a patient receiving an MAO inhibitor, the dose of opiate,
sedative, analgesic, and other premedication be reduced to one-fourth to
one-fifth the usual dose.

Meperidine

Meperidine should not be used in patients receiving MAO inhibitors since
severe, generally immediate reactions, including excitation, sweating,
rigidity, and hypertension, suggestive of serotonin syndrome, have
occurred. Circulatory collapse and death have also occurred following
administration of a single dose of meperidine in some patients receiving
an MAO inhibitor.

Dextromethorphan

Concomitant use of MAO inhibitors and dextromethorphan (ingested as a
lozenge) has been reported to cause brief episodes of psychosis or
bizarre behavior. Cases of apparent serotonin syndrome, including at
least 2 fatalities, have been reported in patients receiving concurrent
MAO inhibitor and dextromethorphan therapy. Dextromethorphan
preparations should not be used in patients receiving an MAO inhibitor.

?Bupropion

Studies in animals using phenelzine have shown that the acute toxicity
of bupropion is enhanced by the MAO inhibitor. Concomitant use of an MAO
inhibitor and bupropion is contraindicated, and it is suggested that at
least 14 days elapse between discontinuance of MAO inhibitor therapy and
initiation of bupropion therapy.

?Anesthetics

The hypotensive and CNS depressant effects of general anesthetics may be
exaggerated in patients receiving MAO inhibitors. Since inhibition of
monoamine oxidase may persist for several days following discontinuance
of therapy, some manufacturers suggest that MAO inhibitors be
discontinued for at least 7?14 days prior to elective surgery to allow
time for recovery of enzymatic activity before general anesthetics are
used. If emergency surgery is necessary in a patient receiving an MAO
inhibitor, the dose of the general anesthetic should be carefully
adjusted.

Patients receiving MAO inhibitors should not be given cocaine or local
anesthetics that contain sympathomimetic vasoconstrictors, since
hypertension may result.

Because MAO inhibitors may potentiate the hypotensive effect of local
anesthetics used in spinal anesthesia, these agents should be used with
caution in patients receiving MAO inhibitors.

?Disulfiram

MAO inhibitors should probably be used with caution in patients
receiving disulfiram. In one study in animals receiving large
intraperitoneal doses of disulfiram and the d- or l-isomer of
tranylcypromine, severe toxicity, including seizures and death,
occurred. However, in other studies in animals receiving large oral
doses of disulfiram and racemic tranylcypromine, no adverse interaction
was reported.

?Metrizamide

Animal studies suggest an increased risk of seizures when metrizamide
(no longer commercially available in the US) is administered
concurrently with drugs that lower the seizure threshold; however, the
clinical importance of such an interaction has not been clearly
established. The manufacturer of metrizamide has stated that MAO
inhibitors should not be used concomitantly in patients receiving the
contrast medium. The manufacturer of metrizamide also stated that MAO
inhibitors should be discontinued, if possible, at least 48 hours before
and for at least 24?48 hours after administration of metrizamide.

?Diuretics and Hypotensive Agents

In general, MAO inhibitor antidepressants should not be administered
concomitantly with diuretics or hypotensive agents since a marked
hypotensive effect may occur.

?Drugs with Anticholinergic Activity

Some manufacturers state that anticholinergic antiparkinsonian drugs
should be used with caution in patients receiving MAO inhibitors, since
severe reactions have reportedly occurred when these drugs were used
concurrently; however, additional information is needed to determine the
clinical importance of this potential interaction. It also should be
considered that MAO inhibitors may prolong and intensify some
anticholinergic effects (e.g., dryness) of antihistamines.
Treeline - 03 Feb 2005 06:05 GMT
> This is probably far too much information, but I'll paste the
> information from Medscape's database. This class of drug, which still
> has applications although never the first choice, has one of the widest
> range of bad interactions of ANY class of medication.  You need to have
> about a two-week period between the last dose of any other
> antidepressant I can think of, and the first dose of MAOI:

Not bad. Depressing that I actually understood all of it. One of the sneakiest
side effect I have heard about is the antibiotic, common erythromycin and
viagra!!!!!!  watch out on that one. i won't tell you what happens because it
can be tragic or comic depending...

But for fibromyalgia or CFS, Elavil, as you suggested is fine for the low dose
antidepressant, just a 1/4 fraction of the usual dose. Just now I was talking
to my ex-gf and she says in her book it also mentions Ambien probably for a
sound deep sleep and something for the muscle relaxant.

Ambien for sleep, 10 mg of Elavil amitrypilene, Zelustril for muscle relaxant
or did she mean Zestril   which would be a muscle relaxant but for the heart,
hmmm. Anyway, Elavil is the antidepressant. My ex was the one when we went to
her internist and I was waiting for her, I read the literature on the table and
diagnosed the CFS according to the silly pamphlet. Her doc, a university doc,
said yes, I was right but that's all I got. But why could he not do his job? it
was his field too. duh.

and now back to our regularly scheduled meow
CatNipped - 03 Feb 2005 16:08 GMT
>> This is probably far too much information, but I'll paste the
>> information from Medscape's database. This class of drug, which still
[quoted text clipped - 33 lines]
>
> and now back to our regularly scheduled meow

My doctor was giving me Neurontin and Effexor (along with Wellbutrin,
Ambien, and Zanaflex) for my fibromyalgia, but I found it didn't really
help - especially after my body got enured to the effects.  And, it was pure
h*ll to get over the withdrawals when I stopped taking it.

(Howard and I have discussed this before - my doctor would not give me a
regimen for discontinuing the medication since he wanted me to remain on it
even though I was losing my insurance and couldn't afford it, so I quit all
my meds cold-turkey - stupid and potentially life-threatening, but I did
manage to get through it.)

Since that experience I'm determined not to get on any other long-term
medications, but I can't get by without the Ambien and Zanaflex - I can't
sleep without them, and when I don't sleep the pain is unbearable.

I can pretty much suck up the pain and still function just using the Ambien
and Zanaflex - the doctor mentioned just last Monday that they were having
success with another anti-depressant in fibromyalgia patients, but I didn't
really listen to even the name of the drug since I'm so determined to stay
away from any other maintenance medications.

Hugs,

CatNipped
Howard Berkowitz - 03 Feb 2005 17:11 GMT
> >> This is probably far too much information, but I'll paste the
> >> information from Medscape's database. This class of drug, which still
[quoted text clipped - 59 lines]
> medications, but I can't get by without the Ambien and Zanaflex - I can't
> sleep without them, and when I don't sleep the pain is unbearable.

There have been some recent studies that confirm Ambien is safe and
effective for much longer periods of therapy than previously thought.
Still, there are some potential problems. I've started using low-dose
Seroquel, which is officially an atypical antipsychotic, but is finding
a number of off-label uses. I find it more gentle and yet probably
giving more refreshing sleep than Ambien.  Roughly comparable cost.

> I can pretty much suck up the pain and still function just using the
> Ambien
[quoted text clipped - 9 lines]
>
> CatNipped
CatNipped - 04 Feb 2005 01:11 GMT
> There have been some recent studies that confirm Ambien is safe and
> effective for much longer periods of therapy than previously thought.
> Still, there are some potential problems. I've started using low-dose
> Seroquel, which is officially an atypical antipsychotic, but is finding
> a number of off-label uses. I find it more gentle and yet probably
> giving more refreshing sleep than Ambien.  Roughly comparable cost.

Hmmmm.  I use the Ambien because it *WILL* put me to sleep in under 20
minutes - guaranteed.  The only problem is that Ambien is made to wear off
in 4 hours.  The purpose of this is that, normally, once a person gets to
sleep they'll stay asleep and wake up 8 hours later without feeling
drugged - but it doesn't work that way for people with fibromyalgia.  I have
a problem with the *type* of sleep I get.  I don't ever go into deep,
"delta" sleep.  I stay in "alpha" stage sleep in which the brain waves
almost mimic being awake.  This means I sleep, well, like a cat.  I wake up
very easily, so after the Ambien wears off in 4 hours I usually wake up
every few minutes after that.

I think the theory behind fibromyalgia is that "delta" sleep is when the
body washes out all the lactate in your muscles, refreshing them, and
repairs all the micro-damage that happens to the muscles all day long.  By
not going into "delta" sleep, this doesn't happen so you wake up feeling
even worse than when you went to sleep.  [OK, Howard, feel free to correct
me - I know I probably screwed this up completely, but it's just what I seem
to remember from the doctor's explanation years ago.]

Anyway, all this to ask, Howard, does the Seroquel work for longer than 4
hours?

Hugs,

CatNipped
CatNipped - 04 Feb 2005 01:30 GMT
> > There have been some recent studies that confirm Ambien is safe and
> > effective for much longer periods of therapy than previously thought.
[quoted text clipped - 16 lines]
> I think the theory behind fibromyalgia is that "delta" sleep is when the
> body washes out all the

lactate <--------------  LOL, my Freudian slip is showing!

Hugs,

CatNipped

in your muscles, refreshing them, and
> repairs all the micro-damage that happens to the muscles all day long.  By
> not going into "delta" sleep, this doesn't happen so you wake up feeling
[quoted text clipped - 8 lines]
>
> CatNipped
Howard Berkowitz - 04 Feb 2005 02:19 GMT
> > There have been some recent studies that confirm Ambien is safe and
> > effective for much longer periods of therapy than previously thought.
[quoted text clipped - 16 lines]
> very easily, so after the Ambien wears off in 4 hours I usually wake up
> every few minutes after that.

> I think the theory behind fibromyalgia is that "delta" sleep is when the
> body washes out all the lactate in your muscles, refreshing them, and
[quoted text clipped - 6 lines]
> seem
> to remember from the doctor's explanation years ago.]

I'm not sure there's any real data on the association with sleep EEG
levels and fibromyalgia.  While the EEG is still probably useful in the
evaluation of convulsive disorders and possibly some organic brain
disease, it's a less important tool now that we have things like PET and
functional MRI scanning. They reveal much more of what's going on in the
brain.  Where EEGs give data on the outside, these techniques image the
inner structures, and -- critically -- chemical activity in them.

One interesting and recent finding, still seeking more data, is that the
parts of the brain that trigger violent emotion develop faster in
adolescent males than the parts that appear to moderate it.

> Anyway, all this to ask, Howard, does the Seroquel work for longer than 4
> hours?

Let's put it this way -- I often need 9 or 10 hours to be rully
refreshed, but if I sleep for 8 or so on it, I usually wake up rested
and don't wake up during the night -- major bed cat activity excepted.
We don't have bedmice, it's just that Mr. Clark weighs about 17 pounds
and sometimes sleeps on parts of my body not quite stressed for it.
Treeline - 04 Feb 2005 17:09 GMT
> I'm not sure there's any real data on the association with sleep EEG
> levels and fibromyalgia.  While the EEG is still probably useful in the
[quoted text clipped - 3 lines]
> brain.  Where EEGs give data on the outside, these techniques image the
> inner structures, and -- critically -- chemical activity in them.

You might want to rethink this a bit. About 9 years ago I read about delta
waves and CFS or fibromylagia. What is extremely handy about EEGs is that you
can fairly easily collect 8 hours or days of data. Try that with an fMRI!!!

Now while the EEGs are taken on the outside of the skull, if you are looking
for delta waves, that's really all you need. If you want to see what the
hippocampus or the amygdala is doing at the tip of the hippocampus, then you
need imaging equipment that can go there. But it's not necessary here for
establishing the lack of delta waves.

But if you want to see what the brain is producing and producing over 8 or 10
or 24 hours, EEGs are fabulous for that. And relatively cheap to do for anyone.
You can walk around with ambulatory EEGs monitoring. Never seen an ambulatory
MRI or PET, have you?

Can you imagine the cost of an fMRI for 8 hours of continuous moderating? And
someone is going to have to sleep inside the tube too? That would be around
$25,000 easily, don't you think?

About PET, I do not know that much about them. What would be the ease and cost?
With EEGs, a person can sleep in a bed as normal, with a showercap that has the
attached EEGs. So they can toss and turn and be observed. Can't observe someone
inside an MRI.

But in any case, the lack of delta waves is easy, super easy to do with EEGs
and was done a long time ago. Why do you say there is "no real data?" Did you
look? I found it back in 1995, so I'm perplexed since you are usually so good
at this stuff. Are you really sure that is not any data with delta waves and
CFS or fibro?

> One interesting and recent finding, still seeking more data, is that the
> parts of the brain that trigger violent emotion develop faster in
> adolescent males than the parts that appear to moderate it.

No, say it ain't so. Really? Never would have thunk it. [testosterone is great
for this - betcha it does not happen before puberty - it's all hormones without
even looking up the studies, i betcha]
Treeline - 04 Feb 2005 17:31 GMT
> > One interesting and recent finding, still seeking more data, is that the
> > parts of the brain that trigger violent emotion develop faster in
> > adolescent males than the parts that appear to moderate it.

Okay, let me get serious this time. The sympathetic nervous system is super
fast, all the time, regardless of age. The parasympathetic nervous system, the
relaxing one or meditating or moderating one, is too slow and often not trained
well in most humans in the western hemisphere. More interest in the eastern
hemisphere, talking globally not brainwise or brain hemispheres :)

It's an interesting finding but expected. Now what part of the brain is
supposed to moderate it? I am perplexed because the parasympathetic nervous
system has its main nexus around the lower tummy area, below the belly button,
the fabled t'an tien in Chinese medicine or mythology, and the upper back
between the shoulder blades, yes? So if you can remember what part they were
referring to, heck, what parts for both nervous systems, that would help. For
the sympathetic nervous system, it's the hippocampus? the fight or flight
system? sound right?

But what part in the brain itself moderates anger? The thinking part in the
prefrontal lobes, the top/front part of the head where thinking and judgment is
supposed to occur. You got me thinking now about this. I have to start going to
the brain gym ;)

Okay, I remember now, the hypogastrium for the parasympathetic complex is the
medical name for what the t'an tien or tan dien for giqong taiji and all those
centering oriental arts. Basically 1 inch below the belly button and 1 inch
inwards. Well the hypogastrium might be simply the name of the area and not the
name of the nexus for the parasympathetic nervous system which mediates violent
responses or really slows down the human being.
Howard Berkowitz - 04 Feb 2005 17:57 GMT
> > I'm not sure there's any real data on the association with sleep EEG
> > levels and fibromyalgia.  While the EEG is still probably useful in the
[quoted text clipped - 20 lines]
> need imaging equipment that can go there. But it's not necessary here for
> establishing the lack of delta waves.

The problem is that we really don't have a decent theoretical
understanding of the different waveforms. We have some clinical
correlations that can be useful in dealing with specific disease
entities. I'm concerned that too much is being extrapolated from brain
waves.

> But if you want to see what the brain is producing and producing over 8
> or 10
> or 24 hours, EEGs are fabulous for that. And relatively cheap to do for
> anyone.

Ambulatory EEGs are extremely useful in the clinical evaluation of
seizure disorders. I have not seen evidence that they give meaningful
data on other brain activity.

> You can walk around with ambulatory EEGs monitoring. Never seen an
> ambulatory
> MRI or PET, have you?

Not really relevant, if I can get a short meaningful sample from
imaging, but continuous data from EEG recording which isn't too specific.

> Can you imagine the cost of an fMRI for 8 hours of continuous moderating?
> And
> someone is going to have to sleep inside the tube too? That would be
> around
> $25,000 easily, don't you think?

I'm still unclear on the need for that period of continuous monitoring.

> About PET, I do not know that much about them. What would be the ease and
> cost?
[quoted text clipped - 3 lines]
> someone
> inside an MRI.

Why not? Indeed, there have been published studies of internal organ
positioning during sexual intercourse, with external video to correlate.
There's no problem putting optical fiber inside the magnetic field of
the MRI.

> But in any case, the lack of delta waves is easy, super easy to do with
> EEGs
[quoted text clipped - 5 lines]
> and
> CFS or fibro?

I'd want to see it. Most neurologists I know are using EEG less and less.

Nerve conduction studies and electromyography are giving interesting
data in fibromyalgia, as are tissue biopsies. I'm unclear if you are
referring to research or routine treatment.

> > One interesting and recent finding, still seeking more data, is that
> > the
[quoted text clipped - 6 lines]
> without
> even looking up the studies, i betcha]

Not directly the hormones, as, for example, the state of the amygdala.
Treeline - 04 Feb 2005 23:27 GMT
> > Now while the EEGs are taken on the outside of the skull, if you are
> > looking
[quoted text clipped - 9 lines]
> entities. I'm concerned that too much is being extrapolated from brain
> waves.

Who doesn't? Delta waves are associated with deep sleep. It's not a theory.
It's simply an observation. What are you saying here? Delta waves are not
necessary? Look, humans need 2 legs for locomotion. It's possible to get by
with one or no legs but 2 legs are better. Same with delta waves. Most normal
or average or healthy people have delta waves in deep sleep. There is not much
here in the way of extrapolation. It's mostly observation. Where do you see
theory or extrapolation? I don't follow your usual excellent line of reasoning.

> > But if you want to see what the brain is producing and producing over 8
> > or 10
[quoted text clipped - 4 lines]
> seizure disorders. I have not seen evidence that they give meaningful
> data on other brain activity.

This is because most of medicine only use EEGs for epilepsy. Most neurologists
do not even understand the difference of bipolar versus referential recordings
for research. It's sad that you have not seen much evidence because it's due to
the stupidity and lack of real scientific knowledge of most docs. They memorize
textbooks and learn how to wear white coats. Most of them could not do any real
science even if you threw them into a lab. EEGs should have been used in
science but even though they are simple pieces of equipment they still require
a knowledge of physics and electricity that is simply beyond the ken of most
doctors. I'm not saying that doctors are stupid per se. They have high IQs. I
am saying they are stupid when it comes to real science.

> Not really relevant, if I can get a short meaningful sample from
> imaging, but continuous data from EEG recording which isn't too specific.

Only talking about delta waves which are sporadic in sleep, like what, 2
sessions of 45 minutes. Are you familiar with deep sleep and the propagation of
delta waves at all? Without going to the internet, I say that deep sleep is
synonymous with delta waves. No delta waves, no deep sleep. But delta is not a
continuous thing, hence the monitoring to make sure that someone goes into deep
sleep.

That is the whole point to this discussion. CFS people do not have delta in
their sleep. Not real delta.
> I'm still unclear on the need for that period of continuous monitoring.

See above.

> Why not? Indeed, there have been published studies of internal organ
> positioning during sexual intercourse, with external video to correlate.
> There's no problem putting optical fiber inside the magnetic field of
> the MRI.

Enlighten me how two people screw inside an MRI. Please! I am amazed at your in
depth knowledge here.

So how come the rest of us have to remain still during an MRI and these people
get to move around during an MRI?

I just don't see how this can be down with high resolution MRIs. Or even low
resolution. How do you do MRIs of moving people?

> I'd want to see it. Most neurologists I know are using EEG less and less.

Most neurologists I knew could only use EEGs for epilepsy because it's at the
idiot level. Frederic Gibbs, the father of EEGs in the USA, once lamented to me
how ignorant most neurologists were in using their EEGs. Truly not understand
the basic physics. They make mistakes. In fact, their ignorance prevents them
from using EEGs because their positioning of the electrodes for bipolar
montages actually destroys the usefulness of EEGs for most research purposes,
other than the very narrow of epileptiform signatures of the wave forms.
Bipolar allows easy viewing of the spike wave form for finding epilepsy which
is what most neurologists can do. Any moron could do it also. It's a very easy
thing to discern.

I cannot recall a single neurologist who understood how differential amplifiers
are how EEGs work and what is the difference between monopolar/referential and
bipolar recordings. It's not difficult. Really first or second year
undergraduate physics or engineering.

> Nerve conduction studies and electromyography are giving interesting
> data in fibromyalgia, as are tissue biopsies. I'm unclear if you are
> referring to research or routine treatment.

10 years ago I read the CFS did not produce or go into deep sleep which is
characterized by delta waves. This is like saying someone's temp does not go to
97 F. It's not theory. It's observation. Now if you are saying that it's
irrelevant, then that's another issue.

> Not directly the hormones, as, for example, the state of the amygdala.

Amygdala is flight or fight.
Now what mediates the opposite? That would be the pre-frontal lobes??? if in
the brain and that's probably the last to develope in human beings, and
probably not developed fully until the 20's for most human beings. This is what
may mediate the parasympathetic nervous system. Unlike the amygdala which is
for the sympathetic nervous system. We are born to flight or fight, for obvious
reasons. And testosterone just exacerbates this. As it does with spatial and
mathematical reasoning. But that's another gender issue. Testosterone goes
together with maleness and violence. Unless a woman has very high levels, then
there are there more spatial abilities. Whether there is also more violence, I
do not remember. It's kind of rare for women, but I believe that very high
levels of testosterone in women also come with high levels of aggression. I
guess if you look into eunuchs you can see if early castration solves the
problem of violence, but might interfere with the math scores on the SATs :)
For the record, Denmark chemically castrated rapists (think of cyproteron
acetate and such) and it worked. They used male hormone drugs.

thanks for your replies. let's see how far this goes. i don't understand why
you are dinging on delta waves since that, for me, is not theory but an
observation. deep sleep entails delta waves. you say this is theory or not so?
enlighten me. i'll try not to be too biased against your reasoning.
CatNipped - 05 Feb 2005 02:07 GMT
> Who doesn't? Delta waves are associated with deep sleep. It's not a theory.
> It's simply an observation. What are you saying here? Delta waves are not
[quoted text clipped - 3 lines]
> here in the way of extrapolation. It's mostly observation. Where do you see
> theory or extrapolation? I don't follow your usual excellent line of reasoning.

I have only experiential evidence, and only my own experience, but having
gone through a sleep study I know that I don't produce delta waves when I
sleep, I stay in alpha stage sleep.  I know from experience that I wake at
the slightest stimuli (tap your fingernail lightly on your desk and that
would wake me).  And it takes me *HOURS* to go to sleep without Ambien - and
only if the room is totally dard and totally silent, and only if I'm lucky.

I always attributed this to my ADHD.  My kids also have ADHD and they would
only sleep 3 or 4 hours a night (so maybe it was a blessing in disguise that
I could keep up with them), but as they got older they were able to sleep
longer and longer until now they can get 8 hours a night.  I still only get
4 hours *IF* I take my Ambien.  So I think the sleep issue is the
cause/result of my fibromyalgia.

I once related here a weird experience I once had where I only got about 4
hours sleep over the course of 5 days - I ended up in the emergency room on
the 6th day.

> Only talking about delta waves which are sporadic in sleep, like what, 2
> sessions of 45 minutes. Are you familiar with deep sleep and the propagation of
> delta waves at all? Without going to the internet, I say that deep sleep is
> synonymous with delta waves. No delta waves, no deep sleep. But delta is not a
> continuous thing, hence the monitoring to make sure that someone goes into deep
> sleep.

And I've heard that it's only when you're in delta sleep that your body
washes out the fatigue toxins from your muscles and repairs the micro-damage
that is the result of normal daily activity.  I don't go into delta sleep,
so my muscles don't ever get repaird, so I live in constant pain (to get an
idea of what it feels like, imagine having lived a sedentary life for about
10 years and then one day swimming for over 5 miles, then imagine how every
muscle in your body would feel about a day or two after that).

> That is the whole point to this discussion. CFS people do not have delta in
> their sleep. Not real delta.

And people with fibromyalgia.  The difference, AFAIK, is the CFS people feel
chronically tired, but the fibro people are in agony pretty much all of the
time.  Did you know that 3 of Dr. Kevorkian's (sp?) "patients" had nothing
wrong with them *except* for fibromyalgia (and who knows how many people
commited suicide without help because of it).  I think that the depression
that comes from knowing you're going to spend every second of your life in
terrible pain is another reason they started treating fibro with
anti-depressions, not just to experiment with pain relief (only my guess).

> 10 years ago I read the CFS did not produce or go into deep sleep which is
> characterized by delta waves. This is like saying someone's temp does not go to
> 97 F. It's not theory. It's observation. Now if you are saying that it's
> irrelevant, then that's another issue.

Going by how it was explained to me (see above), it does make sense that
lack of delta sleep could cause CFS and fibro, if that's how it really
works.  I just don't know if it has been documented that muscle repair
happens *only* in delta sleep.

Hugs,

CatNipped
Howard Berkowitz - 05 Feb 2005 04:11 GMT
> > > Now while the EEGs are taken on the outside of the skull, if you are
> > > looking
[quoted text clipped - 16 lines]
> theory.
> It's simply an observation. What are you saying here?

That we don't have a theoretical basis for the waveform, and, AFAIK, if
they are essential for deep sleep.  Does deep sleep cause delta waves to
generate, or do delta waves induce deep sleep?

I have much more experience in cardiac electrophysiology than brain, and
an intermediate level in nerve conduction. My problem with depending too
much on EEGs, in their present form, is the lack of theoretical
understanding, and the lack of mapping of waveforms to a
three-dimensional model.

> > > But if you want to see what the brain is producing and producing over
> > > 8
[quoted text clipped - 14 lines]
> due to
> the stupidity and lack of real scientific knowledge of most docs.

This is beginning to sound like a rant. Again, my experience is more in
the clinical application of EEGs than in the theoretical work. Maybe
someone is doing serious work in mapping them into a three-dimensional
model, and correlating them with metabolic activity. I simply see the
neurologists I know getting more and more benefit from advances in
imaging, while brain electrophysiology seems to stay static.

> > Not really relevant, if I can get a short meaningful sample from
> > imaging, but continuous data from EEG recording which isn't too
[quoted text clipped - 4 lines]
> propagation of
> delta waves at all?

I need a little more definition of deep sleep, and what you mean by
propagation.  To me, propagation means how the signal moves through
various structures, as, for example, the SA nodal signal in the heart
propagates through the AV node, the bundle of His, and the ventricular
conduction system.

>Without going to the internet, I say that deep sleep
> is
[quoted text clipped - 20 lines]
> your in
> depth knowledge here.

Trying to remember the journal - it was a reputable one. I subscribe to
JAMA and NEJM, so would tend to think it was there.

> So how come the rest of us have to remain still during an MRI and these
> people
> get to move around during an MRI?

Why are some people rich and handsome? :-)  I think they were told,
periodically, to "hold it."

> I just don't see how this can be down with high resolution MRIs. Or even
> low
[quoted text clipped - 12 lines]
> purposes,
> other than the very narrow of epileptiform signatures of the wave forms.

Again, I'm unclear where you are going, other than being upset about
this. I've always felt that EEG placement needed the precision of
stereotactic frames, and correlation with internal anatomy, before it
could tell much of anything.

> Bipolar allows easy viewing of the spike wave form for finding epilepsy
> which
[quoted text clipped - 8 lines]
> bipolar recordings. It's not difficult. Really first or second year
> undergraduate physics or engineering.

Agreed that is basic electrical engineering. That simply hasn't come up
in most discussions, but at least some are quite aware of the design.

> > Nerve conduction studies and electromyography are giving interesting
> > data in fibromyalgia, as are tissue biopsies. I'm unclear if you are
[quoted text clipped - 6 lines]
> 97 F. It's not theory. It's observation. Now if you are saying that it's
> irrelevant, then that's another issue.
Treeline - 05 Feb 2005 06:39 GMT
> > > The problem is that we really don't have a decent theoretical
> > > understanding of the different waveforms. We have some clinical
> > > correlations that can be useful in dealing with specific disease
> > > entities. I'm concerned that too much is being extrapolated from brain
> > > waves.

Sometimes you just have to make do. As far as I know, no one knows how the
waves are formed. But thanks to FFTs originally, we know what waves are being
forms. Has there been any research recently that spells out how the brain makes
AC waves? Yes the cells fire and all, but do they know? I have not followed
this for years and the last brain researcher I talked with said, he really did
not know. But he was an old brain researcher at that point.

> That we don't have a theoretical basis for the waveform, and, AFAIK, if
> they are essential for deep sleep.  Does deep sleep cause delta waves to
> generate, or do delta waves induce deep sleep?

It's possible we don't know anything about what causes the electricity. I would
think by now we do but I have not checked the literature in years. That's not
quite true. I have looked at various brain researchers. Heck, we still do not
know where the engram is.

I do not see your logic here for the clinical point of view. Delta waves are
just slow waves, by definition, in the USA, around 1 to 4 Hz or cycles per
second. They are a bit tricky to detect because artifacts are also around that
range, heart beat is around 1 Hz and eye blinks and what not.

However, and I could be wrong, when people go into what is known as deep sleep,
which is about 45 minutes to what, 1.5 hours for a cycle, it's there that delta
waves are observed.

Let's be more precise. The brain produces a spectrum of waves at all times.
When we say we talk of delta waves, we are really saying the power or the
amplitude of the delta waves have become far more pronounced. When this occurs,
the phyisological signals slow down quite a bit, like heart and other things.

But it's just a way of speaking. Delta waves just mean that the brain is
producing a lot of power in its somewhat lowest AC waves.

At this level, your argument reminds me of the chicken or the egg came first.
It's nice to parcel out the causality but it's not necessary for the clinical
application if it's too complicated. Well, I actually do not see your point of
view at all. For me, delta waves are deep sleep. For the time being, I will say
no delta, no deep sleep. If you wish to split hairs, please do but I am having
trouble seeing the relevancy at this point if no delta means no deep sleep.

> I have much more experience in cardiac electrophysiology than brain, and
> an intermediate level in nerve conduction. My problem with depending too
> much on EEGs, in their present form, is the lack of theoretical
> understanding, and the lack of mapping of waveforms to a
> three-dimensional model.

Eindhoven anyone? I just purchased an EKG or ECG for fun, well, not really. I
am using my own modified Lead II to look for p waves. I am amazed how simple
EKG's are compared to my own building of EEGs. I can build a usable EKG with
about $10 worth of parts. Now for the automatic interpretation, that is
expensive. Really, for the simple leads, not the AV ones, it's just a
differential amplifier.

Now how good are you? I have been having a running battle with cardiologists
and the machines for about 10 years now. They say the machines are
mis-interpreting the data. A big-time professor and researcher agreed with me
that the cardiologists were wrong and the machines were right.

If you are really, really good, how about I send you an EKG and you tell me if
it shows a past heart attack, to use the layman's term, or not?

By the way, when you talk of nodes and so forth, is that not somewhat 2-D? I
could ask you to 3-D the heart. That's really simple compared to the brain. If
you look at the brain as a covering, okay, you want to know the innards. Too
many layers and different type of structures compared to the heart.

Heck, with the heart you can radio ablate and change the abnormal conductions.
Can't do that with the brain easily unless you are cruel and what to do
lobotomies. Well, drugs can do it. Psychosurgery which is cruel can do it. Way
too complicated what you are asking.

The heart is a big muscle and simple to work with. The brain is like hundreds
of muscles and you can't work with it. The skull gets in the way...

> > This is because most of medicine only use EEGs for epilepsy. Most
> > neurologists
[quoted text clipped - 10 lines]
> neurologists I know getting more and more benefit from advances in
> imaging, while brain electrophysiology seems to stay static.

You bet your booty it's a rant. GRRRRRRRRRRR. What can you do when for decades
the neurologists have been destroying the use of EEGs? And their ignorance was
passed on to the psychologists who are even less intelligent, as a rule, IQ
wise, and yes, a rant is putting it mildly. I actually co-authored an article
about this but it was done in scientific speak, so very softy did we call these
people morons.

> I need a little more definition of deep sleep, and what you mean by
> propagation.  To me, propagation means how the signal moves through
> various structures, as, for example, the SA nodal signal in the heart
> propagates through the AV node, the bundle of His, and the ventricular
> conduction system.

The heart is so simple compared to the brain and waves. Propagation for me is
really what I see on the oscilloscope when the electrodes are attached to the
skull. If you want a full theoretical model, we need to get off the cat
newsgroup dude. How about a series of MRIs in a prospective longitudinal study
to start work on this problem? Even basic stuff like schizophrenia is just
starting to be done with models. I find most of the MRI and PET stuff to be
fine but crude. You're asking for something that's way down the line.

> Trying to remember the journal - it was a reputable one. I subscribe to
> JAMA and NEJM, so would tend to think it was there.

They are reputable and even more so since that editor took a hike who was
perhaps, how to gently put it, some questionable practices there at NEJM? New
England Journal of Medicine.

> Why are some people rich and handsome? :-)  I think they were told,
> periodically, to "hold it."

You're kidding, right?

> Again, I'm unclear where you are going, other than being upset about
> this. I've always felt that EEG placement needed the precision of
> stereotactic frames, and correlation with internal anatomy, before it
> could tell much of anything.

If you destroy the data by not understanding how differential amplifiers work,
you basically destroy the opportunity to do research, and that happened for
decades. I was being nice when I said the doctors were being dumb. Actually I
think they are also corrupt because of the damage they do, at least to me, with
their ignorance and greed.

Enlighten me, why do we need sterotactic frames? The system used, A10-20 or
whatever, is overkill because it is really a big problem as you suggest. For
me, EEGs are like temperature or height, really important information. But to
make too big a deal out of it is silly. We do not need to know the height to
hundredths of an inch. Same for EEGs.

Some of the most important findings can be expressed as 2-D. For example,
schizophrenia is a remodeling of the brain that gets out of control, easy to
see 2-D from 3-D modeling. Most of us lose brain cells. The schizophrenics lose
too much during adolescence. Fascinating. It's not mental illness at all. But
really looks like an infection of the brain. Dumb doctors not to realize this.
Took a brain research to nail it down. It's a physical illness with lots of
social irritations and outcomes, to put it mildly.

You do not need to know where the delta waves are or why or what or how. You
only need to know you do not have any. For helping someone. It's like being
four feet tall. Whether someone is 4.01 or 3.99 feet tall is not critical. The
fact they are one foot short is all that is necessary.

E. Roy John tried to formalize this with a series of equations, sort of like
econometrics for the brain but he called it neurometrics. That's about as good
as you can get. Sorry. He published in Science I believe. The first article
quantifying schizophrenia using EEGs and a system of equations.

I know, you'll say it's not 3-D and it's mostly tea leaves. Think of economics,
and you'll get the picture. A 3-D model is fine. Now whose brain do you suggest
we cleave open?

What do you have against tea?
Howard Berkowitz - 05 Feb 2005 15:53 GMT
> > That we don't have a theoretical basis for the waveform, and, AFAIK, if
> > they are essential for deep sleep.  Does deep sleep cause delta waves
[quoted text clipped - 16 lines]
> that
> range, heart beat is around 1 Hz and eye blinks and what not.

Let us assume that deep sleep only is accompanied by delta waves. To me,
that still begs the question of the interaction between deep sleep and
fibromyalgia.  There have been posts about such things as "washing out
lactate", which would seem to have more to do with the Krebs cycle,
glucagonogenesis, and so forth. Before we go looking for causality from
the brain, let's understand the muscular biochemistry closer to the
proposed problem.

> At this level, your argument reminds me of the chicken or the egg came
> first.
[quoted text clipped - 8 lines]
> trouble seeing the relevancy at this point if no delta means no deep
> sleep.

As I say, I am completely confused, at this point, how we have gotten
into a discussion of delta waves from a discussion of CFS and
fibromyalgia.

> > I have much more experience in cardiac electrophysiology than brain,
> > and
[quoted text clipped - 3 lines]
> > understanding, and the lack of mapping of waveforms to a
> > three-dimensional model.

> Now how good are you? I have been having a running battle with
> cardiologists
> and the machines for about 10 years now. They say the machines are
> mis-interpreting the data. A big-time professor and researcher agreed
> with me
> that the cardiologists were wrong and the machines were right.

My experience is that machine interpretation is fairly accurate in 95%
of cases, but expert cardiologists will differ on those interpretations.

> If you are really, really good, how about I send you an EKG and you tell
> me if
> it shows a past heart attack, to use the layman's term, or not?

No, because it's unwise to diagnose a heart attack -- myocardial
infarction -- on the basis of the ECG alone. In my own case, which is
clinically much more one of angina, there are silent infarcted areas in
my heart -- that show with nuclear medicine and some research techniques
along the lines of invasive electrophysiological mapping, with direct
stimulation of tissue to determine if the myocardium is merely stunned.  
These infarcts do not show in my 12-lead EKG.  Even during an acute
anginal episode, my ST segment stays essentially normal.

In my case, the clinical value of electrocardiographic monitoring has
been identifying sick sinus syndrome, and justifying a bradycardia
pacemaker.

> By the way, when you talk of nodes and so forth, is that not somewhat
> 2-D? I
[quoted text clipped - 3 lines]
> Too
> many layers and different type of structures compared to the heart.

3D heart visualization is constantly improving. My personal feeling is
that really useful visualization will require forming the images from
multiple modalities, such as ECG correlated with CT.

> > This is beginning to sound like a rant. Again, my experience is more in
> > the clinical application of EEGs than in the theoretical work. Maybe
[quoted text clipped - 14 lines]
> these
> people morons.

As I have said, brain electrophysiology is not my field. I'm not
prepared to argue, without extensive research, if it has or has not been
screwed up. All I can observe is significant clinical progress coming
from advanced imaging systems, where there seems much less emphasis,
among the practicing neurologists I know, on the EEG.

> > I need a little more definition of deep sleep, and what you mean by
> > propagation.  To me, propagation means how the signal moves through
[quoted text clipped - 14 lines]
> be
> fine but crude. You're asking for something that's way down the line.

I'm really not interested in getting into the depths of brain
electrophysiology -- there are enough other fields that keep me busy.
With respect to the brain, my major interest is pharmacology,

> > Why are some people rich and handsome? :-)  I think they were told,
> > periodically, to "hold it."
>
> You're kidding, right?

Really, no. The study was European, IIRC Dutch or Danish.

> I know, you'll say it's not 3-D and it's mostly tea leaves. Think of
> economics,
[quoted text clipped - 3 lines]
>
> What do you have against tea?

My problem is that I don't see a personal professional payoff to going
into brain electrophysiology. There are enough other fields that keep me
busy trying to stay current with the literature.
Treeline - 05 Feb 2005 20:03 GMT
> Let us assume that deep sleep only is accompanied by delta waves. To me,
> that still begs the question of the interaction between deep sleep and
[quoted text clipped - 3 lines]
> the brain, let's understand the muscular biochemistry closer to the
> proposed problem.

That sounds reasonable. I'm all for detail but my biochemistry is kind of weak.

> As I say, I am completely confused, at this point, how we have gotten
> into a discussion of delta waves from a discussion of CFS and
> fibromyalgia.

Lack of a good night's sleep may be an immediate "cause" - generally any person
deprived of deep sleep seem to begin having some symptoms of CFS, if I recall
correctly. So the notion was that very low antidepressant dosage, such as the
Elavil you suggested to correct my saying SSRIs, could help this. This then led
to discussions of Ambien and deep sleep. I guess we segued from immediate
symptom and correction to etiology. The etiology is not known. But the lack of
deep sleep or Stage IV sleep, usually characterized by delta waves, seems a red
flag. You are skeptical of this because it's not fitting into any model. That
can be. But the lack of delta waves appears a real phenomenon whether it's
meaningful or not, I suggested. For me, it's like having a high fever. Maybe I
don't know what caused that fever or which bug it was, if a bug, but I better
get that fever down if I am to survive.

> My experience is that machine interpretation is fairly accurate in 95%
> of cases, but expert cardiologists will differ on those interpretations.

That's what I thought. But expert cardiologists often do not wish to do any
more analysis than they can get away with, make money, and not be sued, in my
experiences with expert cardiologists. I do not recall a single cardiologist
actually analyzing the ECG. They just blew it off saying even if so it's not
important. Not important to them. But to me? Knowing I had a heart attack, at
any time, is a non-trivial event.

> No, because it's unwise to diagnose a heart attack -- myocardial
> infarction -- on the basis of the ECG alone. In my own case, which is
[quoted text clipped - 4 lines]
> These infarcts do not show in my 12-lead EKG.  Even during an acute
> anginal episode, my ST segment stays essentially normal.

I agree. But if you have nothing else what do you do? Suffer in silence? I am
the one who said based on my personal experience, my heart and pain, AND
supported by the EKG, a heart attack happened. If one cannot get doctors to go
over such basic stuff, they really are almost useless entities, like kings and
princes, their times have passed. Reminds me of Dr. Moses Mendelson who pointed
out in one of his critical book on doctors that when the doctors in Italy went
on strike, the death rate went DOWN, not up, but down. Sounds like Italian
doctors are even worse than American doctors.

> In my case, the clinical value of electrocardiographic monitoring has
> been identifying sick sinus syndrome, and justifying a bradycardia
> pacemaker.

It's probably more difficult to speed things up then slow them down. From my
experience with brain waves, it's far more difficult to speed them up on
purpose than to slow them down. Both are difficult but to train speeding up is,
suprisingly, very difficult to do on purpose. Extremely difficult.

> My problem is that I don't see a personal professional payoff to going
> into brain electrophysiology. There are enough other fields that keep me
> busy trying to stay current with the literature.

At this point, that sounds reasonable. Early in the game, I am not so sure. Big
professors of cardiology once told me that biofeedback for the heart was not
possible or that they knew nothing about it. They were wrong as we know now.
You can regulate the heart. And one of the easiest ways is with a heart monitor
that just counts the beats, like a sports monitor. One cardiologist found this
out, whoppee, and wrote an article about his discovery in 2005, something I
noticed in 1995, but I am not a cardiologist so who cares but me? I am not
familiar with bradycardia methods, only the opposite, tachycardia.
Howard Berkowitz - 05 Feb 2005 21:22 GMT
> > Let us assume that deep sleep only is accompanied by delta waves. To
> > me,
[quoted text clipped - 50 lines]
> attack, at
> any time, is a non-trivial event.

That hasn't been my personal experience with the cardiolgists I see --
now, maybe this is a special case since I can interpret to a reasonable
extent. We often discuss them together.

The reality is that myocardial infarctions or even ischemia cannot
always be diagnosed with ECGs alone. In the emergency care situation,
you may get a higher confidence level with cardiac enzymes, troponins,
or C-reactive protein.  In other words, there is a level at which
further refinements of the ECG alone may not provide much practical
benefit. A few cardiologists I know will occasionally put leads on the
back as well as the chest, but that's about the only variant I see even
among researchers.

My personal experience was that the first real evidence showed up on
thallium exercise SPECT scan, and needed coronary angiography to
confirm.  On both exercise and physiologic stress, my ST segment stayed
isoelectric. Stress echocardiography did reveal reversible myocardial
akinesia.

Why did we go to the additional tests?  Continuing exercise-induced
pain, even with some medical therapy. Within a month of onset of
symptoms, I was scheduled for angioplasty.  This was good practice --
not ignoring the patient.

Later on, I had another angioplasty, and then bypass. About six months
after the bypass, I reoccluded two grafts, and my HMO refused to work
them up. Luckily, I was able to find and join an NIH Clinical Center
atypical chest pain protocol, and am now on long-term monitoring at NIH.
I'm occasionally a volunteer for new cardiac imaging, and typically
spend an inpatient week about every five years for extensive testing.  
The good news is that much of my cardiac pathology has reversed with
aggressive medical management.

Apparently, I had bad genetics as far as developing heart disease at an
early age. My father died of a MI and complications at age 42, and was a
cardiac cripple for several years before that, in the early sixties when
cardiologists didn't have much to offer.

In my case, medical and surgical intervention preserved function long
enough that my heart has grown new collateral circulation, my output
fraction is back to near-conditioned-athlete levels, and the left
ventricular hypertrophy is gone. If I lose a good deal of weight, I
expect even more benefit, as well as better control of diabetes.

> > No, because it's unwise to diagnose a heart attack -- myocardial
> > infarction -- on the basis of the ECG alone. In my own case, which is
[quoted text clipped - 14 lines]
> kings and
> princes, their times have passed.

I understand the concern. In general, I can get good cooperation from my
physicians, and we share and discuss all results and strategies. When I
run into a problem, as with the HMO not approving a workup, I know
academic and research medicine well enough to game the system into
providing adequate care.

> At this point, that sounds reasonable. Early in the game, I am not so
> sure. Big
[quoted text clipped - 5 lines]
> monitor
> that just counts the beats, like a sports monitor.

My pacemaker is quite adaptive to changing conditions requiring
different rates. IIRC, it senses both motion and oxygen concentration.

?One cardiologist found
> this
> out, whoppee, and wrote an article about his discovery in 2005, something
> I
> noticed in 1995, but I am not a cardiologist so who cares but me? I am
> not
> familiar with bradycardia methods, only the opposite, tachycardia.

There continues to be significant improvement in the broad category of
implantable cardiac devices.  Where most packemakers are atrial and
ventricular on one side, dual atrial pacing appears to be quite helpful
in several conditions including cardiomyopathy.  Of course, the
implantable defibrillators can be lifesaving.
Tanada - 06 Feb 2005 16:00 GMT
Man, I hope you two are friends, as I'd really hate to see you two in a
p*ss*ng contest.

Pam S. bemused
Treeline - 07 Feb 2005 08:03 GMT
> Man, I hope you two are friends, as I'd really hate to see you two in a
> p*ss*ng contest.
>
> Pam S. bemused

We have a friend in common, called truth. Try it, you'll like it :)
Treeline - 07 Feb 2005 08:01 GMT
> That hasn't been my personal experience with the cardiolgists I see --
> now, maybe this is a special case since I can interpret to a reasonable
> extent. We often discuss them together.

That's good. Did you hit textbooks on EKGs? They are amazingly expensive
although the info is old and old textbooks can be good enough.

> The reality is that myocardial infarctions or even ischemia cannot
> always be diagnosed with ECGs alone. In the emergency care situation,
[quoted text clipped - 10 lines]
> isoelectric. Stress echocardiography did reveal reversible myocardial
> akinesia.

How did you know it was reversible? Reversible by better echoes or they could
tell somehow? Akinesia is what some called hypomotility?

> Later on, I had another angioplasty, and then bypass. About six months
> after the bypass, I reoccluded two grafts, and my HMO refused to work
[quoted text clipped - 4 lines]
> The good news is that much of my cardiac pathology has reversed with
> aggressive medical management.

That's amazing. New cardiac imaging? Invasive, catheterization or noninvasive
such as Fast CT Scans or echoes?

> I understand the concern. In general, I can get good cooperation from my
> physicians, and we share and discuss all results and strategies. When I
> run into a problem, as with the HMO not approving a workup, I know
> academic and research medicine well enough to game the system into
> providing adequate care.

Good for you. You have a lot of patience. I guess I could do that. But I am not
so sure I want another MRI ever, for example.
Howard Berkowitz - 07 Feb 2005 14:19 GMT
> > That hasn't been my personal experience with the cardiolgists I see --
> > now, maybe this is a special case since I can interpret to a reasonable
> > extent. We often discuss them together.
>
> That's good. Did you hit textbooks on EKGs? They are amazingly expensive
> although the info is old and old textbooks can be good enough.

I have several.  Also, the major cardiology textbooks like Hurst have
extensive chapters.

> > The reality is that myocardial infarctions or even ischemia cannot
> > always be diagnosed with ECGs alone. In the emergency care situation,
[quoted text clipped - 14 lines]
> could
> tell somehow? Akinesia is what some called hypomotility?

In basic testing, reversibility is defined by having normal perfusion
(SPECT) or visible movement (echocardiography) before the stress (by
drugs or exercise), and no perfusion/movement afterwards.

> > Later on, I had another angioplasty, and then bypass. About six months
> > after the bypass, I reoccluded two grafts, and my HMO refused to work
[quoted text clipped - 9 lines]
> noninvasive
> such as Fast CT Scans or echoes?

An assortment. Transthoracic (against the chest) and transesophageal
(down the throat) echocardiography, with drug-induced stress, and an
assortment of imaging enhancements including several different acoustic
contrast media and additional computer processing for three-dimensional
visualization. SPECT using different isotope protocols. Radionucleide
angiography (also called multiple gated ucquisition (MUGA) or
radionucleide ventriculography). MRI before the pacemaker.
Catheterization/angiography, including a new technique called Biosense,
and an assortment of intracardiac drug stimuli.

Biosense has a couple of elements. First, and most generally, the tip of
the catheter has a small attached magnet, and the patient is surrounded
by coils, so the catheter tip can be precisely located in
three-dimensional space -- you can only estimate the third dimension in
convention fluoroscopic angiography. Second, in this protocol, they
administered electrical stimulation to various parts of the heart
muscle, to differentiate between true scar tissue and "stunned"
myocardium that would recover with new blood supply.

During that last procedure, the cardiology fellow, who was English, and
I engaged in a bit of dialogue that delighted half the team and utterly
confused the rest.  When he would find scar tissue after finding stunned
myocardiun, I'd respond "'es not dead! 'es merely resting!"

"It only stays there because it's nailed to the rest of the heart! It's
gone off and joined the choir eternal! THIS IS EX-MYOCARDIUM!"

It was probably revenge for the chief of invasive cardiology, an
Iranian-American, demanding really bad country and western as procedure
background music.

> > I understand the concern. In general, I can get good cooperation from
> > my
[quoted text clipped - 6 lines]
> am not
> so sure I want another MRI ever, for example.
Treeline - 08 Feb 2005 19:31 GMT
> I have several.  Also, the major cardiology textbooks like Hurst have
> extensive chapters.

Thanks for the tip. They sure are heavy, around $300 by now?

> In basic testing, reversibility is defined by having normal perfusion
> (SPECT) or visible movement (echocardiography) before the stress (by
> drugs or exercise), and no perfusion/movement afterwards.

> An assortment. Transthoracic (against the chest) and transesophageal
> (down the throat) echocardiography, with drug-induced stress, and an
[quoted text clipped - 5 lines]
> Catheterization/angiography, including a new technique called Biosense,
> and an assortment of intracardiac drug stimuli.

That's great. My mitral valve is a big problem here. Everyone says it's a
judgment call. You say tomato I say tomatoe. Whether a T-E-E or regular, the
leaking cannot be quantified or really known for sure. Great. So I do not know
if I have a grade of F for miserable severe Failure or just D for depressing
moderately severe because the jet is "eccentric" like me ;)  It's great you get
good data and somewhat reliable results. Everything for me is mostly judgment
calls and when I call the shots, I improve. I sure wish I could trust the
doctors as you do so superbly. You must have great social and communication
skills. I don't have any - must be another defect with the "connective tissue,"
this time in the corpus callosum.

> Biosense has a couple of elements. First, and most generally, the tip of
> the catheter has a small attached magnet, and the patient is surrounded
[quoted text clipped - 4 lines]
> muscle, to differentiate between true scar tissue and "stunned"
> myocardium that would recover with new blood supply.

Thanks for the "tip." I "sense" that. Love puns, sometimes.

> During that last procedure, the cardiology fellow, who was English, and
> I engaged in a bit of dialogue that delighted half the team and utterly
> confused the rest.  When he would find scar tissue after finding stunned
> myocardiun, I'd respond "'es not dead! 'es merely resting!"

That's really funny.

> "It only stays there because it's nailed to the rest of the heart! It's
> gone off and joined the choir eternal! THIS IS EX-MYOCARDIUM!"
>
> It was probably revenge for the chief of invasive cardiology, an
> Iranian-American, demanding really bad country and western as procedure
> background music.

I never did this, with or without music. Bad decision on my part, very, very
bad. Now it does not really matter, too late. Well, I am hoping that
researchers in Scotland come up with a nice, bionic valve and I can afford it.
I went to the best in the USA, Cleveland Clinic, what a dump, poorest city in
the USA in 2004, cannot afford a good infrastructure, bad nursing, bad
supporting doctors, regardless of  reputation where the "mistakes" are buried
in the ground or in the high numbers so it's not obvious they screw up
big-time. Can't sue in Ohio unless dead or paralyzed, then it's easy,
especially if you are dead. I'll stop before I start ranting.

What is your ejection fraction before I forget? Around 55%?