The
Massachusetts CFIDS/FM Association
UPDATE
Our
quarterly publication covers topics of interest to the CFIDS/FM community
in the Commonwealth of Massachusetts, Nationwide and Worldwide. The better
part of the table of contents for the current issue is listed here. You
can read a few articles online. Follow the links. Your subscription to
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the Massachusetts CFIDS/FM Association. We welcome new members from all
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Please feel free
to contact us at update@masscfids.org.
Spring
2002 Issue (57 pages)
Mass. CFIDS/FM
Association's Quarterly Publication
CONTENTS
Features
In a recent presentation to Mass. CFIDS/FM
Association, neurologist Dr. Roy Freeman described his CFIDS study findings and
those of a wide array of other researchers working on the same basic questions.
Dr. Freeman said he hoped his own work would lead to potential treatments
“within a year, perhaps two.”
Dr. Freeman is internationally known for his work on the
autonomic nervous system (see Primer on ANS) and for the past five-plus years he
has concentrated on the relationship between the ANS and CFIDS. Outgoing
president of the American Autonomic Association, as well as an associate
professor at Harvard Medical School, Freeman directs the Center for Autonomic
and Peripheral Nerve Disorders at Beth Israel Deaconess Medical Center in
Boston.
His work on CFIDS began in the mid-’90s, after talking
with Dr. Anthony Komaroff about a new, “provocative,” research article
documenting autonomic problems in CFIDS. The two teamed up to test for possible
CFIDS-ANS links, using patients from Komaroff’s study group and the advanced lab
technology available at Freeman’s neurology center. Their study spawned further
collaboration, and ultimately Freeman launched his own series of ANS/CFIDS
studies at BI-Deaconess.
While he is indeed a serious scientist who holds research
studies to high, rigorous standards, Dr. Freeman has an engaging, non-serious
sense of humor as well. His was a lively, fast-paced lecture, full of
give-and-take with listeners, while he tossed around specialized medical jargon
as well as catchy slang and jokes with equal ease. His talk interspersed
findings from studies he’s conducted with those of other current researchers and
earlier work.
Stressing that scientists’ understanding of ANS phenomena
in CFIDS/FM is still preliminary, he prefaced many of his remarks with such
asides as “Science is funny...” or “Here things get a little murky, kind of
messy,” allowing listeners to take a breath before trying to comprehend the
difficult, complex issues at hand. And difficult they are, even for those who
have read or heard much about the ANS before, as the research continually enters
more sophisticated, arcane levels.
(Subscribe to The Update to read this 12 page
article and many more timely pieces.)
-
Orthostatic Problems in CFIDS/FM & Post Polio Syndrome by
Richard L. Bruno Ph.D. (2 pages)
-
Orthostatic Intolerance & CFIDS by Dr. Peter Rowe (2
pages)
-
New England Premiere
of “I Remember Me” by Rita Sanderson (3 pages)
-
Davida and Goliath by Jane Colby (2pages)
-
Social Security Benefits for CFIDS & FM by Alec Sohmer
Esq.
Departments
Association Announcements:
Introducing the New President’s
Circle by Diane Turner
Flying High Fundraiser: Hot
Air Balloon Festival
New Writing Contest/ Fund Raiser!
by Sharon Wachsler
More Announcements:
CFIDS/FM Awareness: How You Can Help by Diane Turner
Coping Corner: CFIDS/FM Caregivers: What Can You
Do? by Caroline Goode
Advocacy Alerts:
Members Meet with Congress in Washington DC by Diane Turner
Name Change Workgroup Report
News for Youth and Families:
Orthostatic Intolerance & CFIDS by
Dr. Peter Rowe
Disability News: Social Security Benefits for CFIDS
& FM by Alec Sohmer Esq.
Research and Treatment News: by Lucy Dechene PhD
Conference Summaries:
Report on the ACR Rheumatology
Conference by Lisa Lorden
Report of the AAAS Meeting in
Boston by Lucy Dechene, Ph.D.
Medical Journal Summaries: by Lucy Dechene, Ph.D
Journal of CFS Summaries
Fibromyalgia Medical Journal
Summaries
CFS Medical Journal Summaries
********
In Their Own
Words:
Orthostatic Intolerance
and CFS-- New Light on an Old Problem
by Dr. Peter Rowe, Johns Hopkins Medical School
"Chronic fatigue is a prominent symptom in a variety of
overlapping syndromes of circulatory dysfunction, the most notable examples of
which are neurally mediated hypotension (NMH) and postural tachycardia syndrome
(POTS). An early suggestion that such abnormalities were treatable causes of
symptoms in what we now call chronic fatigue syndrome (CFS) was made in 1940 by
Alexander MacLean and Edgar Allen. They described a group of patients who
experienced excessive acceleration of the heart and hypotension after moving
from the recumbent to the erect posture, usually associated with symptoms of
orthostatic exhaustion, blurring of vision, weakness on exercise, and syncopal
episodes. McLean and Allen attributed the tachycardia to a reduced venous
return to the heart, in part because symptoms and hemodynamic changes could be
provoked within 10 seconds by Flack's test, which involved forced expiration
into a tube to maintain a mercury column at 40 mm, thereby reducing blood flow
into the thorax. They concluded that this orthostatic tachycardia syndrome
seemed similar to “effort syndrome, irritable heart, or neurocirculatory
asthenia” the synonyms of the day for what we now call CFS. McLean and Allen
reported that patients improved by increasing their intake of fluids and sodium,
and by sleeping with the head of the bed elevated. The head-up bed may have
helped to conserve intravascular volume by reducing blood flow to the kidney at
night. It is a medical curiosity that these detailed observations were largely
ignored for several decades.
In this issue of The Journal of Pediatrics, 3 articles address related
aspects of orthostatic control of blood pressure and heart rate, two of which
take advantage of newer methodologic tools to better understand microvascular
flow and cerebral oxygenation. In 23 healthy adolescents, Stewart noted that
44% had reductions in blood pressure of >20 mm Hg systolic in the first minute
of upright tilt to 70 degrees, associated with transient symptoms of
lightheadedness. At a formal level, these patients met the adult criteria for
orthostatic hypotension, but in contrast to the usual course in adults, the
hemodynamic changes resolved during one minute and did not require treatment.
The reduction in blood pressure correlated with increased calf blood flow
measured by strain gauge plethysmography. These valuable observations provide a
physiologic explanation for common and self-limited episodes of lightheadedness
in adolescents, and they support a conservative approach to treatment, provided
resolution of symptoms is rapid. Stewart suggests a need for better pediatric
norms for the response to orthostatic stress, and as we generate these, we will
be wise to make them age-specific. There is now good evidence that pubertal
children have a greater susceptibility to orthostatic stress than prepubertal
children. Although the mechanisms for this change in susceptibility during
adolescence are as yet unclear, the observation is in agreement with
epidemiologic and clinical impressions that orthostatic intolerance syndromes
and CFS are much less prevalent in prepubertal children.
The paper by Tanaka et al brings further insight to the pathophysiologic
features of symptoms during upright posture in patients with CFS. In
orthostatic intolerance syndromes, it has been widely assumed that
lightheadedness and other symptoms are caused by a reduction in cerebral blood
flow. Our own studies using transcranial Doppler ultrasonography do not
identify a distinctive pattern of cerebral blood flow velocity during upright
tilt in adolescents and adults with CFS and orthostatic intolerance compared
with controls. The much earlier onset of symptoms during head-up tilt in
patients with CFS suggests that other factors not measured by transcranial
Doppler may play an important role.
Near infrared spectroscopy (NIRS) offers a different insight into cerebral
changes during upright posture. This noninvasive technique measures changes in
the absorption of near infra-red light by oxygenated or deoxygenated hemoglobin
and can be used to assess changes in cerebral tissue oxygenation rather than the
changes in blood flow velocity that are available through transcranial Doppler
studies. NIRS has been used to study cerebral oxygenation in a variety of
settings, including upright tilt in patients with syncope, during lower body
negative pressure (a simulated orthostatic stress), and in neonates. Tanaka et
al used NIRS to compare cerebral oxygenation between 20 healthy controls and 28
patients with either CFS or idiopathic chronic fatigue. Sixteen patients with
chronic fatigue had hemodynamic evidence of orthostatic intolerance during a
brief 7-minute period of active standing, compared with 2 of 20 controls of a
similar age. After an initial drop in cerebral oxyhemoglobin at the onset of
standing in most controls, 18 of 20 experienced a rapid recovery. In contrast,
only 7 of 28 patients with chronic fatigue had a rapid recovery, and reductions
below the basal level were more common in patients with CFS than in controls.
Of interest, 6 of 12 patients with chronic fatigue and abnormal cerebral
oxygenation had no evidence of orthostatic intolerance during the 7 minutes of
standing, although it is impossible to know whether these patients would have
gone on to develop hypotension after a longer period of orthostatic stress.
The results of this study are intriguing but will need to be corroborated by
others. Further support for the relevance of reduced cerebral oxygenation to
the development of CFS symptoms will depend on showing whether cerebral
oxygenation normalizes in patients whose CFS symptoms improve either
spontaneously or with treatment of the orthostatic intolerance. It will be
important in future studies to ensure that the orthostatic stress is
sufficiently long to identify clinically important NMH, which in most cases
would be missed by a 7-minute test. Another noninvasive technique that would
add to such studies would be the incorporation of end-tidal carbon dioxide
measures, to assess the effect of changes in carbon dioxide tensions on cerebral
blood flow and oxygenation.
In the third article, Stewart provides a concise summary of the growing
literature on the pathophysiology and current treatment of common syndromes of
orthostatic intolerance. Treatment of these disorders begins, as it did in
1940, with education, reassurance, dietary measures, postural maneuvers to
prevent blood from pooling in the limbs, the use of compression garments, and
avoidance of situations that provoke symptoms. An underappreciated aspect of
management is the need for effective control of other comorbid conditions that
may independently contribute to orthostatic intolerance, including allergies,
asthma, dysmenorrhea, migraine headaches, movement dysfunctions (especially
those associated with joint hypermobility), and anxiety and depression. Failure
to bring these problems under adequate control in the setting of clinical trials
will lead to underestimates of the effect size of any intervention. Of the
medications that have been proposed, stimulant medications may have received
less attention than they may deserve in the treatment of pediatric orthostatic
intolerance, despite being used as therapy for hypotension long before their
discovery for the treatment of attention deficit disorder and hyperactivity.
As Stewart notes, clinicians have few randomized controlled trials available to
guide their decisions about treating orthostatic intolerance, and even fewer
when it comes to medications targeted to adolescents. Further progress is
likely to come as we gain an improved understanding of the pathophysiologic
heterogeneity of these syndromes, but in the interim, a much greater effort
needs to be devoted to treatment trials. One methodologic challenge posed by
the heterogeneity of these disorders is that randomized trials of single agents
will need large sample sizes, thereby making them rather unwieldy to conduct and
expensive for funding agencies. A more economic design for the determination of
efficacy of medications may be to study treated patients at a stable point in
their illness. Persons who have improved by using a medication assumed, but not
proven, to be efficacious could be randomized to either active medication or
placebo. This randomized withdrawal design would have the advantage of being
relatively brief in duration, less costly, and low in new adverse events. If
cerebral oxygenation is consistently abnormal in patients with orthostatic
intolerance and CFS, its measurement may prove useful as a more objective marker
of the response to treatment than self-report of symptoms."
(Source: This is an
editorial from The Journal of Pediatrics
2002 Apr;140(4):387-9)
*********
New England Premiere
of I Remember Me
by Rita Sanderson
On April 9th, 2002 I had the good fortune of
attending the New England Theatrical Premiere of the highly-acclaimed film about
CFIDS/FM, "I Remember Me.” This program was organized by Mass. CFIDS/FM
Association and included a guest appearance and presentation by the film's
Director, Kim Snyder. The Premiere took place at the Brattle Theatre, a
relatively small but cozy movie revival house in Cambridge, where many
documentaries, independent and foreign films are the mainstay. The 250-seat
theater is often referred to as Boston's unofficial film school. The theatre
was filled to capacity for the first showing.
This was a very compelling and informative account of
“life with CFIDS/FM.” This 74-minute documentary film was directed by Kim
Snyder, an experienced filmmaker from New York, and a person with CFIDS/FM.
This film marks Kim's directorial debut. Her film credits include documentaries
i.e. Oscar-winning film Trevor, and feature films i.e. Home for the
Holidays. The film focuses on Kim's personal struggles with CFIDS/FM and
her pursuit of answers over a 5+ year period. Snyder’s reflections and
revelations about her own experience took on the form of an interview that was
intertwined with stories of other people with CFIDS/FM, observations by a
variety of clinicians and researchers, and visits to key locations. In between
the dialogue and these clips, a mixture of scenes were interposed, such as the
storminess of the sea, seclusion by the riverside, the fury of a strong wind
tearing across the fields, and buildings crumbling to the ground – visual images
that conveyed to me what I believe were Snyder’s innermost feelings and
suffering.
Snyder’s quest for information took her to Lake Tahoe, Nevada, site of
one of the first known clusters of this mysterious illness during the mid-1980s,
where an extensive conversation with Dr. Dan Peterson was recorded and presented
in segments. Dr. Peterson showed genuine concern about people who had been
well, suddenly became ill, many still remain ill, and those who had taken their
lives over the years. He also expressed disgust with the sloppy investigation
conducted by CDC and NIH officials who left skeptical that anything unusual had
taken place. A clip was also shown of Dr. David Bell who spoke about a similar
occurrence in upstate New York.
A number of other doctors were interviewed including Drs.
Nancy Klimas, Peter Rowe, D.A. Anderson, and Alexis Shelekov, and several
others, all of whom strongly supported the serious, complex nature of this
illness. They reported on their clinical or research experiences. Commentary
by Dr. William Reeves, former branch chief of the CDC, was also included
regarding the diversion of funds from CFIDS studies and acknowledgment that
CFIDS has become a major health problem. Contrary to these opinions, Dr. Peter
Manu, an ill-informed doctor, was filmed at one of the CFIDS conferences saying
that he believed CFIDS was nothing more than a form of hypochondriasis, where
patients and advocating doctors have been trying to "create" or turn it into a
"real" illness.
Another comparable, but earlier outbreak of a CFIDS-like illness occurred over
40 years ago in Punta Gorda, Florida. Snyder was able to identify and meet with
several of the women who had become ill but they had no idea, until recently,
what had happened to them. Apparently, a medical article had been published
about their cases but no one had ever gotten back to them. There were three
other significant interviews. One was with Michelle Akers, Olympic gold
medallist and world’s top soccer player, who spoke with a lot of emotion and
frustration about her experience (she has since had to retire from soccer due to
CFIDS.). Another one was a rare discussion with Blake Edwards, a famous
Hollywood film director (Breakfast
at Tiffany's,
Days of Wine and Roses,
Pink Panther) and husband of singer Julie Andrews. Edwards was very candid but
cynical about his struggles with this illness.
The most touching of all the interviews was the story of
Stephen Paganetti, a young high school student from Conn. At the age of
sixteen, this boy had a very abrupt change in his health and quickly became
bedridden for over 2 years. He had to be home-schooled and have all his daily
needs taken care of by his parents, including being fed through a tube. The
film recorded the exhausting preparation for his graduation where he was brought
by ambulance while receiving IVs and oxygen. He was wheeled on a gurney to
receive his diploma. Later on, he was surrounded by many of his former
classmates, some of whom made thoughtless remarks. None of them had ever paid
him a visit at home during that time.
The film moved reflectively from past to present through numerous
scenes, people and places capturing certain experiences that I feel effectively
portrayed the kind of roller coaster ride Kim Snyder and most of us have been
on. All the tests, brush-offs by local doctors, ridicule by other people, and
the overall frustration, isolation, and pain are situations that I, and my
peers, could readily identify with (with the exception of the severity of
Stephen's case). A segment was included regarding suicide. Each of the leading
CFIDS/FM doctors admitted to having lost several patients over the years, mainly
due to pain, and in one case, driven by the total disbelief and disregard by
local doctors making this individual’s life unbearable.
At the end of the film, the audience enthusiastically
applauded Kim Snyder and expressed great appreciation for all the seven years of
hard work that she put into making and marketing this film. It was a true labor
of love! It was also a critically-acclaimed success garnering the following
awards: Winner Best Documentary, People's Choice Award, Denver Film Festival;
First Runner Up, Sarasota Film Festival; and Honorable Mention, Hamptons Film
Festival.
Patients could say that they are already intimately
familiar with this illness, so why go and pay to see a movie about it? All I
can say is that people went to show their support for an incredible
accomplishment by someone who has walked in our shoes. This film also provides
a great opportunity to educate family and friends who still don't understand
what CFIDS/FM is and how it impacts our life. Most importantly, our patient
community now has a great new tool to educate medical professionals and others
who don't quite get it. We thank Kim Snyder for her enduring legacy! For most
of us, it took us one day (and perhaps another day or two of recovery) to see
the results of Snyder’s investment of 5+ years in the making of this film. She
has been traveling to film festivals and screenings over the past year or more,
making it a seven-year journey.
A lengthy Q & A session with Kim took place after the
first showing of the film. She responded to dozens of questions from the
audience who praised this award-winning film. She recounted her now seven-year
experience working on this film. A couple of questions were raised concerning a
few aspects that may have been overlooked in this film. One is the "poverty"
that is often brought on by this illness, and the other is the need for a more
accurate representation of the "ethnic" groups afflicted by this illness.
Viewers felt these aspects ought to have been included. Other questions
included: why Fibromyalgia had not been mentioned to which Snyder answered that
her research used the terms/definitions coined during these early outbreaks that
she had investigated. She recognizes that FM and CFIDS are intertwined, and she
acknowledged having both. In response to one of the last questions, she
announced that after 7 years, she found herself doing considerably better – for
no explainable reason other than “luck.”
This film was aired
several times during April on the Sundance Cable Channel. I am not sure if it
will be broadcast later this spring or summer. You can check their schedule at:
www.sundancechannel.com. Last but not least, please note this film has now
been released as a video tape and made available for purchase at:
www.irememberme.com and copies are available at the Mass. CFIDS/FM
Association’s lending library.
Rita Sanderson is on the Board of Mass. CFIDS/FM
Association and is our very committed Support Group Coordinator. Special Thanks
to both Rita and Tamara, as well as our heart-felt thanks to Kim for this great
film.
********
Speaker Preview: Dr. Bruno will be our
next speaker in the Mass. CFIDS/FM Association's continuing Medical Lecture
Series. His lecture topic will be "Common Ground: the Connection Between CFIDS/FM
and Post Polio Syndrome."
Orthostatic Problems in
CFIDS/FM and Post Polio Syndrome
by Dr. Richard L. Bruno
While watching a football game President Bush swallowed a
pretzel and fainted. They said it irritated his throat and made his blood
pressure fall. I feel faint when food seems to get stuck behind my breastbone.
I also get lightheaded and very tired after a big meal. Other people with CFIDS/FM
tell me they do, too. Are these CFIDS/FM symptoms?
President Bush swallows a pretzel that irritates his esophagus. The irritation
causes his blood pressure to plummet and he faints. An unheard of experience?
Not for some of the world's 20 million polio survivors and the estimated 10
million people with CFIDS/FM.
The President's problem likely had to do with the pretzel overstimulating the
vagus nerve, the main highway for nerve traffic to your esophagus, your
swallowing tube, and to your stomach. The vagus nerve carries commands from
brain stem neurons to activate the muscles in your throat, esophagus and stomach
that make swallowing possible. The vagus nerve also sends commands that tell
your heart muscle to slow down and your blood vessels to open up. Vagus nerve
stimulation, causing a drop in blood pressure due to blood vessels opening up,
is responsible for the common faint, called vaso-vagal syncope.
But the vagus nerve is a two-way street: it both sends commands to your heart
and gut and listens to the results of those commands. The vagus carries
information about how much food is inside your throat, esophagus and stomach
back to those same brain stem neurons. Anything that irritates the esophagus--
like a pretzel getting stuck or even a full stomach -- can stimulate the vagus
nerve enough to drop blood pressure and cause a faint, which seems to be what
happened to the President.
For Mr. Bush this is likely a one-time thing. But for polio survivors and
people with CFIDS/FM, low blood pressure, lightheadedness and even fainting can
be frequent occurrences. We know that the poliovirus damaged brain stem neurons
that control the vagus nerve and possibly damaged the nerve itself. We have
been following a growing number of post-polio patients who feel exhausted after
eating meal. Food sticking in the esophagus or a full stomach apparently
overstimulate the vagus nerve, trigger a drop in blood pressure and cause
feelings of severe fatigue, even though these polio survivors don't usually
faint.
In 1995, pediatrician Peter Rowe found that some patients with CFIDS also have
fatigue that is associated with a drop in blood pressure when they stand up,
take a hot shower or are in a hot room. Rowe's observations parallel the
finding from our 1985 Post-Polio Survey that fatigue increased in more than one
third of polio survivors when they were exposed to heat. Another parallel with
polio survivors was Rowe's observation that a CFIDS patient had "a purple
discoloration" of her feet and hands after standing. This discoloration was
reported in patients with CFIDS back in 1959 and is remarkably similar to polio
survivors' cold and purple "polio feet." These findings indicate that both
polio survivors and some CFIDS/FM patients have lost the ability to regulate
the size of their veins, which allows blood to pool, blood pressure to drop and
causes feelings of fatigue.
Our 2001 International Chronic Fatigue Syndrome Survey found that those with
CFIDS/FM fainted nearly twice as often as they did before having CFIDS/FM. Our
1995 International Post-Polio Survey found that polio survivors do not
faint any more frequently than those who didn't have polio. But the 1995 Survey
did find that anyone who had fainted even once in their lifetime reported
significantly more severe daily fatigue than those who had never fainted. This
suggests that damage to brain stem blood pressure control and vagus nerve
neurons may be coupled to damage to brain activating neurons, the neurons that
our and others' research suggests are responsible for symptoms of "brain
fatigue" in polio survivors and those with CFIDS/FM. So polio survivors and
patients with CFIDS/FM share abnormalities of blood vessels and blood pressure
that seem to be related to brain stem neurons that are not functioning normally,
probably as a result of virus damage to both brain activating and blood pressure
control neurons.
What's to be done? Everyone with CFS should have their heart rate and
blood pressure taken lying, sitting and standing. If fatigue is associated with
a drop in blood pressure, compression stockings are often helpful to stop blood
from pooling in the legs. If you need more help, go to a specialist in low
blood pressure and ask about medications that increase the amount of fluid in
your blood or reduce the size of your veins to stop blood from pooling in the
legs. If fatigue is associated with meals, eating small bites and washing them
down with liquid, as well as eating frequent, small, higher protein meals, can
stop food from sticking in the esophagus and the stomach from getting too full,
prevent over stimulating the vagus nerve and prevent fatigue or even a faint.
REFERENCES
Bou-Holaigah I. Provocation of
hypotension and pain during upright tilt table testing in adults with
fibromyalgia. Clinical & Experimental Rheumatology, 1997; 15: 239-46.
Bruno RL. The Polio Paradox: Uncovering the Hidden History of Polio to
Understand and Treat "Post-Polio Syndrome" and Chronic Fatigue. Warner
Books, 2002.
Bruno RL. Paralytic versus non-paralytic polio: A distinction without a
difference? American Journal of Physical Medicine and Rehabilitation,
1999; 79: 4-12.
(ftp://members.aol.com/harvestctr/Library/npp.html)
Bruno RL. Fainting and Fatigue: Causation or Coincidence? CFIDS Chronicle,
1996; 9(2): 37-39. (ftp://members.aol.com/harvestctr/Library/faint.html)
Bruno RL. Chronic fatigue, fainting and autonomic dysfunction: Further
similarities between post-polio fatigue and Chronic Fatigue Syndrome? Journal
of Chronic Fatigue Syndrome, 1997; 3: 107-117. (ftp://members.aol.com/harvestctr/Library/ffans.html)
Bruno RL, Frick NM. Stress and "Type A" behavior as precipitants of Post-Polio
Sequelae. In Research and Clinical Aspects of the Late Effects of
Poliomyelitis. White Plains: March of Dimes Research Foundation, 1987.
Manyari D. Abnormal reflex venous function in patients with neurally mediated
syncope. J Am College Cardiology, 1996; 27: 1730-5.
Palmer E. The upper gastrointestinal vasovagal reflexes that affect the heart.
Am J Gastroenterology, 1976; 66: 513-22.
Rowe P. Orthostatic intolerance and chronic fatigue syndrome associated with
Ehlers-Danlos syndrome. J Pediatrics, 1999; 135: 494-9.
Dr. Richard Bruno will be our next speaker in the
Mass. CFIDS/FM Association's continuing Medical
Lecture Series. Dr. Bruno is the Director of Fatigue Management Programs and
The Post-Polio Institute at Englewood (NJ) Hospital and Medical Center. His new
book, The Polio Paradox: Uncovering
The Hidden History of Polio to Understand and Treat “Post-Polio Syndrome”
and Chronic Fatigue, will be published by Warner Books in June. See his
website at
www.postpolioinfo.com. E-mail any questions to Dr. Bruno at
PolioParadox@aol.com
*******
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