DysCourse: Managing Chronic Fatigue in Autonomic Disorders with Dr. Nancy Klimas, MD

DysCourse: Managing Chronic Fatigue in Autonomic Disorders with Dr. Nancy Klimas, MD

During DysCourse, Dr. Klimas joins us via hologram to discuss tools for managing Chronic Fatigue in autonomic disorders.

so um thank you for inviting me and uh thank you for the amazing making truth yours that have been talking to you in three dimensions very very cool although I do love that dude from that campus out over the bay so missing that but everything is kind of different kind of neat anyway you were kind enough to invite me to your conference and uh you were trying to draw for me my experience with the mecfs uh the population that I've learned so much of um the management uh in these complex elements of using patients that have sort of many diagnosed development ones so I thought I'd just approached their broad question of achieving achieved a really tough question to approach because there are so many different reasons to have the cheap all right let's go together so anyway I was saying I'm gonna put the big broad uh concept of fatigue and what causes fatigue and that just right from the beginning and the often hearing people say that the eskimos have 20 different words for the word snow what continues like that what do you mean by fatigue you know there's different types of fatigue it's physical fatigue good mental fatigue there's emotional fatigue and there are Concepts around fatigue there's the idea that fatigue is a cellular energy exhausted that's one possibility sometimes fatigue is coming from signals in the brain that signal fatigue fatigue fatigue go less and that's another kind of fatigue um sometimes it's been balance of all the systems that regulate your body and its energy system like the thyroid hormone for instance is very important for energy and yet in a complex network of other hormones and it needs to have a nice balance and then they fatigue we've all experienced this the emotional safety valve after they've sort of had an emotional meltdown and afterwards you're not energized right you feel like you need to go to bed for that so there's different weird triggers and reasons for having fatigue I've worked in mecfs now since that 80 is a long time and I've learned an awful lot and most of what I've learned I've learned from my patients but I have a scientist and clinician when we do a lot of studies but I will say he's taking your two years and understanding what your patients are telling you is often the most important part of understanding what's wrong with people on how to explore the reasons they bring the fatigue so um one thing that we have on in all these shares is that there's a lot of different mediators that are injured by the balance each other that have to be with um when white people stay exhausted so most kind of be this is the model I use it for mbcfs but actually works for anything genetic predisposition then something makes it happen a trigger and then a whole host of mediators keep it going so on and so forth all these things are fighting alone that result in illness persistence so most of the work we do in our research is with people who are already sick right so we mostly care about media we mostly care about Hawaii stay that way and we'd like to know you know why didn't we have that way but we really want to know how to get you out of that way so most of my work that's been in that aviator's face so when you break it down there's many contributions to fatigue includes like I said body system cells the brain sleep cannot historic how important sleep is and having fatigue kind of dull but it's amazing how many people think that three to four hours affective enough to to go on and then go through thousands of dollars worth of work up to try to figure out why they're particular when we've got basically aren't sleeping enough um pain and then the medication to your honor the nutrition and contribute to fatigue so just start at the beginning energy comes from your body making energy and we mostly rely on something called aerobic energy meaning that we need oxygen and glucose at a cellular level to make energy so right away it relies on your lung excuse me and not just your lungs the ability of your heart to pump blood through the lungs to pick up that oxygen and not just your heart the ability of your body to make all those red blood cells to pick up the oxygen as it grows through the lungs so that's a really important factors to having enough oxygen delivering to the tissue and then there's a third thing it's really relevant to dysautonomia and that's your microvasculature the tiny little vessel the thread the vessels that go to Every millimeter of your tissue to deliver those red cells and sometimes there's clamped down because they're back vessels and they cannot deliver the goods to the tiny tiniest little distal tips of those vessels and getting that oxygen to uh when you need the most and so getting oxygen is a really important thing now there are some conditions that that's up the lungsman COPD from your fibrosis particularly post covenants which are seeing more and more of that and dysautonomia more often than not it's vascular meaning the vessels are inspound and adrenaline and they're not delivering um a nutbox into the very chips and chips of their of the tissue I mentioned the heart and the body systems of energy that absolutely delivering uh blood around so I always say the heart is pimples some types of wiring well sort of you know nothing simple but it is um it's worth what types you want vessels and it's wired with electricity yeah with the wiring from your brain it felt it what to do and it's affected by your blood volume now I'm going to say what volume matters we don't talk about it very much but we've done studies in nacfs to show the average patient is a neither short a leader that's like almost a quarter of the blood volume sure um and you're trying to get all that oxygen kicked around your body with 75 of the cells that you need to do it so right away you've got a problem right so one volume and a much ignored genetically important and treatable face um that uh can affect energy the efficiency of the pump I'm going to talk about that for a moment and then getting the signals right how is it wired and many of you have experienced tachycardinal pots popularity syndrome there you're beating like crazy right your heart's going 120 times a minute but between every beat you need enough time for the heart to fill up so it can efficiently squirt that blood back out and deliver it to the good so if it gets too fast it's increasingly less efficient and then able to push that um the motherland effectively and so the efficiency of the pump matters and the muscle itself whether it's strong enough or if it's got me um too thick to uh to allow the blood to get in and then I already talked about the veins and the arteries and the ability to contracted that way but most of you would just I don't know we have looked down at your feet when you're standing up and said oh my gosh they're blue but that's your veins very dilated right it shouldn't be like that they should be contracting enough the the literally the gives above your belly button so the average this autonomia patient when you look at their volume of blood you're the bottom and half of their body and they have 70 of their blood volume below the belly button and that's only 30 percent up here I can either and a half a blood at best to take care of your lungs your heart your brain a whole lot of space up here uh and it's not a lot and it's all down there and there's dilated vessels hanging out not being very helpful so when the the um doctors are saying that compression piles and things that can pressure veins they're trying to deliver the volume of blood you need back to the heart so it can do its job and get that around the tissue so we talk about autonomic dysfunction see the balloon speed gap for the number five the um the pink feet versus blue feet um that is basically um autonomic dysfunction and so many things in partial Orthopedics hypertension sympathetic over Activation Syndrome and they're all lumped together under this umbrella terminal function and that's the purpose that some people have more than one of these diagnosis drawing on so one cheap and easy way we do in our only Clinic is everyone who walks in the clinic every single patient has something called the natural winter that's from NASA the astronaut band right and they do this through the astronauts to see if their autonomic function is being affected by being in space and when they come back from a mission where the first thing that happens is they lean them up against the wall often but this nice person on the wall here for 10 minutes an intense cereal blood pressures and impulses and see what happens what should happen which you shouldn't have more than a 10 per minute change or I mean dropping your blood pressure but if you get a 30-seat change or a 30 job you need the diagnostic criteria and do not need to go get jump cable you can just go right ahead and call that frankly at this autonomia patient with boxer and then they you know one of those diagnosis depending what you found it's like I call it the chief the chief and just like a tilt you can't leave a patient leaning on the wall because patients get dizzy and fall down they can pass out you have to be there for and so this is a test that and then play it can train people to eat for athlete and um the patient you know we can be getting their whole oral history while they're leading with the wall which is not waste that time the meanwhile again is nice about measure that's super helpful okay so getting these signals right they start an army and you you know in this family to repeat it you'll already have effects of lecture today but the autonomic nervous system wired everything everything that's important in your body it requires your brain IT wires your heart why are you lungs and why is your GI trap why is everything and so it's no big surprise but people will just autonomy had symptoms everywhere and so it gets so confusing when you walk in your doctor's office and you have idea of gastric paraparesis and you have tachycardia and arrhythmia and this and that the other thing that I could blowing their eyes for a month it was patient but in fact they're just saying hey I have did that a moment that's what they're saying so um so it's an important thing to say and we often talk about you know the balance the uh the the sympathetic parasympathetic pattern and so when I sit down from sitting in three minutes I have a first event but I've never just been turned on and give me more false more contraction from more blood back up to the heart but within three minutes I auto correct and we put the parasite effects of remember right they'll do a little wobble and then I settle right but with that 10 minute lean chat what you see is people going this sympathetic or they're yelling the Paris empathetic and they don't correct and now they're having a lot of symptoms in 10 minutes into our Loom test they're still they're not back in there when you go down so that's a regulatory problem and there's a lot of different reasons that that might happen as you can see in this that um generally called the parasympathetic the best relaxing store side right so you've got help you sleep better um so it's doing more of the quiet gentle meditative things improve your parasympathetic State you can read and increase your parasympathetic State there's a lot of exercise you can do for parasympathetic um sympathetic is adrenaline they'll go go go go so on my adventure the patients here hyper Vigilant from you know learning how to sing with one eye open they don't learn that they never lose that right they stay hyper Vigilant and so they stay in the sympathetic system and it's fair to having terrible uh background in the body because they are not perishable that way they're not digesting they get a lot of occupation and symptoms and they've got their hyper Vigilant they're having meaning in the PTSD said even if we're done that symptoms there and that's you know something that happens from having your seesaw get out of whack and giving you a Wednesday so in the um one of the most common findings we find when they order cardiograms and young Asians it's something called diastolic dysfunction and if you look at this little picture the heart beating that top Chambers are the um the Atria and in the bottom changes of Adventures and normally they build up the Atria and when they fall the valve up has been dropped it into the ventricle and then The ventricle gets even a good solid pump out and you've got a nice book during your your lungs into your body depending on the side of your heart but if the if the dial stop the Atria that we have time to fill before it blocks it the blood into that um ventricle then you just don't have as much blood flow because you didn't get the volume Into The ventricle and this is a very very common problem this can happen for a lot of different reasons probably the most common reason I see for a diastolic dysfunction is collectible it's simple volume like the blood violence low his attack and cardia that responds not enough kind of trainings to fail and the stretchy step is in the heart respond to the low volume by asking for more speed of the heart more adrenaline and it just vicious that goes the whole thing so getting the blood volume into a normal state would set simple things like salt and electrolytes and sometimes more things like digital Cortisone and other kind of drugs that increase your blood volume um and make this normal dynamic in the heart improved but you can see in this side on the far side the diastolic dysfunction is important naturally North the doctor needs to know about it then you go cardiologist if they don't know what to do about it because overturned that ventricle will work so hard it will get a fat muscle a hypertrophic muscle and then it can't feel right now you have it changed in the heart that's going to keep this going and so it's something that you're going to sell diet stuff that's work too it's not it's actually a very important eel that it needs to be addressed so implications for treatment in this pump and wiring thing is that you fill the space there's ways to do that you regulate the pumps sometimes we slow it down when it's going too fast and for instance maybe that point scoring too slow you compress the vessels in the legs where things are cooling and that's why compression elements that kind of thing are so important um and gently recondition I say gently because reconditioning can flatten our patients let me see if patients cannot be sent off to physical therapy and say do a cardiac rehab program they will be flattened by that program but doing the kind of program that has you doing little bits of aerobic exercise just as much as you can tolerate not enough to make you feel bad the next day which is usually two or three minutes three or four times a day I usually say put a recumbent bike in the middle of your living room and use it two or three minutes three or four times a day and get a little aerobic conditioning going there or do pedals in the air on the bed lying flat there's a whole lot of beautiful website in the deciding only association's webpage on how to do exercises safely when you're decided on an acetylene test so moving along to mitochondria cellular energy matters and mitochondria is the PowerHouse of the cell we learned that in high school and it's still the same I went through medical school didn't change one grit but it becomes a it's a very important space because in chronic fatiguing illnesses sometimes the mitochondria power down now mitochondria will power down if you just don't ask them for energy so being really deep conditioned affects the number of mitochondria they have how efficient they are so just that lack of exercise is enough to drag down energy production in itself but um another thing that's very serious and can be easily addressed is oxidative stress when mitochondrionic energy aerobic energy they're using this thing called the pep cycle they're making energy and they throw off these things called free radicals that are toxic to the cell and there's a whole other pathway it snags them up recycles them and puts them back into the energy thing so it's this perfect little figure eight inside the cell making energy cleaning up the mess making the energy cleaning up the mess that's how it works but if it gets ahead of itself then there's three radicals that can't be cleaned up by the cell they start tearing up the mitochondria's membranes and they and then you don't have enough mitochondria in that cell and eventually the cell itself will die and so I'd say stress again another thing we go hahaha actually it's just one I've said stress is a big deal by the time you're 40 every healthy person is in a negative balance and is already suffering from oxidative stress if you eat a really healthy diet all kinds of greens and rainbows and all like that you'll have a lot less of it but still just on age you have oxidative stress but if you are a hypo profusing if you're not bringing oxygen to yourself you're gonna go into outside of stress because there's a second pathway that cell use when it doesn't have oxygen called the anaerobic pathway and it weighs way more free radicals than the aerobic pathway it's much more destructive and so it's very important to think about how to say the stress and eat the green rainbow diet green red orange all the things without absence in it but also seriously consider a healthy antioxidant supplement because it makes a difference so free radicals oxidative stress now what about the brain so a lot of that that I just spoke about the tricky thing that we sit around and something thinking about was I just ordered a lot of antioxidants on this patient are they going to cross the blood-brain barrier are they going to get where I need them to go and the answer is mostly not but a lot of that the antioxidants be most commonly yet have a really hard time Crossing and getting into the blood into the brain so glutathione the body is most important antioxidant is a terrible um an accident from crossing the blood-brain barrier but it's precursor and a single cysteine Mac NAC gets across really well and so there's been some beautiful studies Now by Dr shund Cornell in mecfs showing that NAC ilocysteine can reverse to normal the oxidative stress in the brain of the pregnancy test so I use a lot of math though in our clinical practice and the patients definitely paint other difference now this says for a show we can actually do imaging now that looks at oxane stress in the brain as prequel that's new so we can tell and that's what Dr Shangri did with this this before and after images of the brain using an antioxidant and seeing it right across why does that matter to fatigue well of course the brain is where could you rest the most that's the whole area of your brain that tells you if you're tired of your energy if you have whatever all that's going on in the brain so I talked a bit about antioxidants I talked a bit about mitochondria one way to get anybody to make more mitochondria is to use it using your body using your brain makes your brain make more mitochondria using your muscles makes your muscles make more mitochondria and so this idea of using exercise Journey positive exercises using your brain that's really important it probably plays a lot actually into neurodegeneration it's why people who have are deaf or more at risk because not using that part of their brain they can't cure anymore people who are um who are um not challenging your brain enough at higher risk people are learning new things as they age have brain that's growing but I know in any CFS there's some studies that show the actual brain mass as shrinking and it's the brain mask where the thinking goes on so I when I saw that my patient sort of panicked I said that is not neurodegeneration that's not using your brain and it's shrinking so so let's let's do this let's do something different let's try to challenge that brain and see if it can grow and in fact other people not argue that they'll study essentially didn't in fact show that they could get brain growth with a cognitive behavioral therapy in which teaching and that type of thing So speaking more about cellulose fatigue I talked about mitochondria um but I didn't talk about how much each individual cell is affected by what it's spinning in okay because the cells are wrestling with receptors and The receptors are telling the cells what to do and they're swimming in the blood and the blood has got all the hormones and cytokines and humankinds and these are signalers so this is what most of our research sits is in this space where the how is the body communicating across all these systems and is it an in a good balance and the answer is no it's not in the big balances so The Chronic sick balance and so um our work actually is all about whether or not you could reboot or change those balances back to a normal balance so we spend a lot of time in this idea of complex interactions of systems and the hormones cytokines immune regulation neuropeptides from the brain all very important um peptides from everywhere peptides in the brain they've got they're everywhere but um but they all um are a player in this this uh these illnesses that are driven when the symptoms so when you're talking about the brain you're talking about um the space in your body that thinks we know that the space in your body the brain stem that manages all the things that that are just I don't know me about your pulse and your blood pressure and so on that's that's within your brainstem but this very central part of the brain where you have emotions and feelings and and The Sensation of fatigue or the sensation of energy happiness sadness it's all in that same general area this tiny little part of the brain and they they're regulated by the um their peptides and then inflammatory symptoms that signal severely in the area so when we're looking at our patients the mecfs patients and the Gulfport illness patients and along cognition patients what do we see inflammation in the brain and out of state of stress and they're playing off each other and if you would imagine I'm gonna challenge the people in the room here because this is an older technology but there's something called CB radio you know the one with the chopper juice and it's got all this background noise and they play around with a doubt and they can get a signal but you can imagine your brain is a radio signal census signals going on and if it's just a noisy loud environment how is the right signal supposed to get through to tell your brain to do this subtle level Corrections that keep us going from minute to minute second to Second making these adjustments so this noisy inflammatory Upstate stress brain has a lot to do with why the hormones are are just subtly off why the other neuropeptides are just subtly off or sometimes big time off but um but our idea in our research in our clinical care has been let's fix things we can fix we can fix out sedative Stress Check we can fix inflammation check and then see who's left and you have someone who's a whole lot healthier when you take care of the brain and and take care of these um either the background noise if you would of saying stress and information and hopefully you're also reducing the risk for for more serious consequences like neurogenesis and the other thing that's going on in the brain is all the regulations and that is a big deal because sleep has stages in fact say it has three stages and uh sorry the language changes with time but the very most superficial stage is is that when you're not quite asleep or just barely asleep and you can hear anything in the room that hyper Vigilant sleep that is not restorative and yet that is the patients with fibromyalgia are trapped in that is the sleep that PTSD patients are trapped in and many many many of our patients that have these other illnesses are trapped in this Alpha wave sleep so we can get them down into a deeper stage of sleep you'll see more the storage sleep and you'll see a healthier patient so we deal a lot with inflammation they'll do a lot with inflammation uh in the brain in our in our in our care and um and we have a lot of reasons too there's a lot of good signs to prove that the information that was just some images of a pet stamp in 2014 and has since been validated by every group that's left in any success population that there's sort of scattered areas of inflammation all throughout the brain and we know as I said that the hormones themselves are just regulated and they're just regulated particularly in two areas the adrenal gland which is also regulating your blood volume um and your stress hormones cortisol your anti-inflammatory hormones and it's just regulated in your um your neck your gonadal hormones estrogen and testosterone and these are really important buyers and barriers that we can measure and treat and so um these are areas that in our and our models of how we should and really reboot the system back to towards normal we have to pay a lot of attention to in our in our research models because when we are look at information of stage stress hormone balance and turns out that we're using cocktails of approaches that are dealing with all of those different areas in order to envisioning our computerized models of how to make people better um that we have to fix three buttons to actually make the difference you can't just focus on one thing I'm going to mention one cell because it's an under discussed cell but it's called the mast cell and when people have um web volume problems then is synonymous if they have mass activation they're going to trigger a lot because mast cells make mediatives that vasodilate that make the vessels leak that do a lot of different things and in mecfs and among coven mast cells are major prayers in the inflammatory side I would have rested at Nova to have Dr uh the Rarities on our faculty is amazing he's the number one master expert in the planet and he's in our group our group and he teaches us so much I've been so lucky we can join our group as we all feel like women are Wizards now and there are things you can do to prevent Mast Cell Activation and someone who are simple neutral suitables so trying to take mast cells quiet by stabilizing their membranes the most powerful thing is is steroids but North Korean steroids so you back up into nutraceuticals like glutiolin and persogen and antihistamines that mop up the mediators that get about these are important players now you think that mast cells are going to be anaphylaxis I'm going to drop down and get the swell up but in fact mast cells can provides a lot of miserable disease just by leaking a little bit all the time and just losing these nasty mediators that they have um so taking care of them to try to reduce inflammation and although there's a dilation and uh things start happening in your arterials because of mast cells that's a good Target for treatment another treatment that we have we use is low-dose naltrepzone this is not not um FDA approved so I have to say that you guys if I didn't Naltrexone itself though the drug that we're diluting is approved and it's approved to the very high dose at 100 milligrams and the studies in Darwin logos now check so the doses one to five milligrams much much lower dose and what it's doing is something very different than it does at that high dose so that high dose is blocking opioids and it's used to treat people with their target addictions for the reverse someone who's had an overdose but it needs long doses it's fighting inflammation in the brain and it does a good job of it and it doesn't vary safely and so um we we use the library heavily on this is our uh one of our key players that we use for brain inflammation the other one we often use human verbal but um one that is or either like the syllable or Nano human circuits across the blood River the other thing I talked about being fatigue achieving um I'm sorry this is a lot of academics and decided to get mail trucks and you shouldn't be on opiates and um sometimes it increases your dream state which is generally help me to restorative but it's your PTSD it can give you nightmares and then it's not so good so 15 15 of people get um increased streaming it's always warning people and if they have trouble with it use it in the morning instead pain is another common cause of um or sleep and then achieve as a pain um so the fibromyalgia patients have a best patients to describe this in we use local Snapchat zone is our number one treatment for fibromyalgia I want maintenance FDA approved fibromyalgia joints which reach different other Americans institutions notice that none of these are opioids these are all right change they look like that's a fibromyalgia diagram of all the devices that the doctors program that make you occur to prove now fibromyalgia has changed a lot in the last 10 years has been worked to show that it's more likely than not an autoimmune disease small fibers than variable nerve endings the sensory nerve endings called small fiber and neuropathy and clinical trial cells going on through that weekend with globulin and they're looking very promising so it may be one of those diseases that has a treatment for the highly effective now that we know the cause already so are you talking about sleep for a moment I'm going to say there's a lot of things about sleep I know decided to leave patients take me to say this but you should do sure then to go to sleep and okay because if you're arresting it all day the ability in response you have when you go to bed you fall asleep is just ruined it's better than lay up sorry on the couch than the lay of sorry in your bed because you've been shooting something you've conditioned yourself that follows them um so you should avoid that you should have a bedtime at the same bedtime all the time there are some sleeping pills that actually track you in four stages of sleep to be there it's called vaccine of validating the drugs and there's something don't and so um it's important each doctors prescribing these things to understand that we don't want to track publication or fighting patients or alcoholic sleep will say you intervenes um foreign [Music] medications that aren't necessarily signal classes of England's and sleep studies that's really important I did a study in my own population that I sent to Six studies and we saw sleep apnea way more often than we expected to and it was not predicted by being short with the short neck or overweight Long Tall a long skinny people with long necks had sleep apnea so anyone that says I can't um when I wake up I'm exhausted sleep study everyone if they have not restorative sleep study make sure you're not dealing with something that's totally treatable and very dangerous to ignore emotional fatigue I'm not spending any time on it except to tell you it's a real thing and um and um a lot of patients that we experienced a lot of hopelessness and sadness because they're so sick and they have perhaps exhaustion in part because they're depressed and that's real and it's treatable and it should not be ignored it's very dangerous and that and people blow off people's depression all the time like oh up you can't yourself up out of depression you have to actually do something about your depression and and go seek professional help I will also say I need primary care doctor now prescribes antidepressants but psychiatrists are the experts they actually know a lot more than I do than all my primary care friends do they actually train to treat this for years and years and they're good at it so don't be embarrassed to go see a psychiatrist who can help with a mood related problem and it's perfectly okay there's biologic reasons to have um depression all those neuropeptides I talked about and then there's just I'm so tired of being tired I'm exhausted I can't do it anymore so what I want to end this lecture on is Hope if you should never feel hopeless in an area where we're making rapid advances in research and We're translating it to to new interventions and new types of things that we can do so and they're running out of town I wanted to mention there's things you can do that aren't drugs by manipulative medicine the osteopathic way of choosing a lot of different kinds of chronic pain conditions acupuncture very helpful yoga and um gentle stretching a lot of people have had a Stamos syndrome we can't over stretch but you can stretch within your limits um using antioxidants um and no cell stabilizers like I mentioned how very helpful and there's some nutritional Dimensions you got to be careful about particularly licorice you're going to be very careful a lot of people with decide to know me to take it because it's the thing we make Florida it causes you to retain fluid which is something good but it causes you to retain fluid because she's sucking up salt and spitting out potassium and if your potassium goes too low urinal a lot of trouble so and it feels like fatigue before your heart stops so you really won't notice the symptoms since your self-achieved that your potassium's dropping and then you're in more trouble because you're getting it in a very seriously passing it slow so I'm really argue against licorice root as a nutritional um intervention unless you're getting earplugs checked then okay but if you're not checking your potassium don't do that another one is over hydration a lot of people are drinking gallons of water and literally gowns and that's crazy because your poor little kidney can't do that it rinses out the entire system that causes you to concentrate urine and now you're diuresing you're getting even drier because your kidney can't hold back the fluid anymore it doesn't have the way to do it so don't overdo the solutions all right time with salt we're doing logical science um we're making tremendous Headway again ending on the on the hope that hope is the most important thing we're doing here this concept that we might be able to reboot the systems back into a normal balance it's very exciting but we also have a lot of clinical experience and these are the things that affect people um a lot when we identify them if you're in a moldy environment you're constantly exposed to toxins particularly mycotoxins you could be poisoning your cells and that could be a big fun don't do it okay so that's a really important thing South Florida is a huge deal um and then um as I said that working within your energy envelope not exhausting yourself and you're beating yourself up to get better to the point when you're exhausting yourself trying to do that you can't even shouldn't be doing this is probably the two take your message is Ace and make sure you're not eating or knitting in a toxic environment emotionally physically or biologically so um we'll end up with we're trying to UA inventions about these paths is a really important points that we're working on our group and many average and we're during the slowest static reading experiments to try to move it um to clinical care it's all foreign yes this is a sure that concept it's a moonshot you know that if they can cure people in the computer model and the animal model for before we ensured the animals so that was exciting and we moved to Cuban based on the animal model and that vcfs there's no animal models so we're just near the human but we're using safe so it should be okay we've learned a lot of sharing a lot you're going to learn a lot more how's that I'll take your questions thank you I'm just curious with all the research if you are recruiting patients for studies absolutely so we have three focused illnesses in our group we do mecfs long all good and Military toxic injuries so our research sort of circles around those groups um so um uh but we're repeating in all those areas and we have you know about 18 different clinical trials going on if you go to our web page you can see a lot more about what we're doing so backslash Nim so NSU well Nova WBU backslash Nim and I am okay here's another question right here kind of like do you use the website one more time is it no regarding you backslash m is in Nancy or neuro I as in the news and Amazon universe so how often do you see autonomic disorders and what Kelly is it and your CSF population how often do you see it it's actually part of the case definition the person has to have fatigue because um moderate to severe and either cognitive complaints and or Dishonored so it's part of the case definition okay any other questions we have another one out of here still on if a sleep study is something that we should all be participating in essentially if we're fatigued do we is there anything specific that we need to be asking the tech or telling them to help make sure we get the appropriate diagnosy yeah and there's there's three different things that they look at when they do a sleep study they look at whether your brain is telling your lungs to breathe correctly that's the rarest form of a sleep problem but it happens and looks at whether or not your throat closes so much it actually stops your breathing that's sleep apnea right and how many times a minute that happens or an hour that happens face and diagnosis but there's something that they don't watch close enough it's called upper Airway resistance it's when your throat almost closes and you can make you can understand your fatigued right if you do anything for very long you know you feel that it's been cheap even holding your eyes open sometimes it's fatiguing but can you imagine all that long trying to keep your Airway up so um a lot of patients have this upper Airway resistance and they're really helped with with um with CPAP with positive pressure it keeps their airways open okay great any more all right Dr Glamis thank you so much sir on our side now you can get out of the little box and go back to your normal normal daughtery so thank you so much for your time we appreciate it I wanted to do the Mind thing I wanted to bring it away Roger thank you again so much we appreciate it

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