In which I answer all your questions: Weekly MastAttack Q&A, Week 1

Hey, MastAttackers,

After a several month hiatus, I am back answering questions in the MastAttack Facebook group. A new thread is posted weekly where people can comment with their questions. Questions are answered on Thursday nights from 7p-9p EST. Once the session is over, the thread is locked but will stay visible so it is available for reference.

The lovely Mikal Mowdy, mother of Yssabelle Eddlemon, who is disease free and living a normal life after a bone marrow transplant, made a PDF with all the questions and answers from last night. You can read it here: Week One PDF

Anyone who wants to participate is welcome. Request to the join the MastAttack FB group and an admin will approve you.

For this coming week only, the Q&A session will be on Wednesday from 7p-9p.

Hope to see you all there!

Lisa

 

The really important things require much more than that

I have two best friends named Allison and Alyson who are both very, very into music. With few exceptions, all of my musical influences arrived to my ears via one or both of them. Alyson lives in Seattle. Alli and I went to visit her there in 2014 when I had a PICC line and 40 lbs of steroid weight and a constant flirtation with anaphylaxis.

While we were visiting, the three of us went to Portland, Oregon for the weekend. It was a really amazing and cathartic experience for me. It feels like that was when I began to reclaim myself and my body and my life. It was an experience I will never forget.

Alyson has always been the type of person who follows bands around the country because she is much cooler than I am. In the last few years, she has been obsessed with Kasabian, a British rock band. She flew into Boston for less than 48 hours to see them in Boston two days after seeing them in New York and a few days before following them to Chicago.

I hadn’t really heard much Kasabian before but tonight I went to the Kasabian with Alli, Alyson and Alyson’s mom, Charlene. We were having some hairy health care moments in the line outside, waiting to get in, so I wasn’t really sure how things were going to go. But I decided that if we got into the venue that I was going to be a huge Kasabian fan for the duration of the show. It didn’t matter that I knew virtually nothing about them. I knew I loved the people I was with. I was happy to be well enough to even go to a concert. So I was a Kasabian fan. Sometimes it’s enough to just believe something, even when there’s no good or logical reason for it. Believing is enough.

We stood right up front and jumped up and down and screamed at the band. I really shouldn’t have sang along since I knew literally no words but that has never stopped me before. I jumped and bounced and screamed for two and a half hours. The energy in the crowd was amazing and the show was great.

I said to Alli tonight that I think that concert years are like dog years. I am therefore 132 concert years old. It sure as hell feels like it. I’m going to need a cane to walk tomorrow. No thigh blaster workouts necessary.

The Portland Sisterhood does Kasabian

I have a Wall of Hopeful Things in my home office space, where I do most of my MastAttack work. It is covered with things patients or parents have sent me. There is a trinket dish on my Wall of Hopeful Things that says, “It is not enough to put your heart and soul into something, the really important things require much more than that.” I think of this as the MastAttack motto. You can’t build something without leaving pieces of yourself among the blocks.

In the last few weeks, I have painstakingly mapped out the next year of my personal, professional (work) and professional (MastAttack) worlds. I have monster goals for MastAttack for the next year. I have started putting together the materials for the course videos for the spring. I have been networking a lot to work towards some other MastAttack goals. I have professional development and program goals at work. I have lots of personal things that I have forced myself to find time for. It is an intimidating amount of life I am trying to fit into these time constraints. But I decided that I could do it, and as soon as I did, I became capable of it. You have to believe it and hold your nerve. So here goes nothing.

Hope you all are having a super weekend. Be on the lookout for some MastAttack announcements this week.

It is not enough to put your heart and soul into something. The really important things require much more than that.

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, Part 60

74. Is mast cell activation the cause of many other diseases?

No, but it is involved in many other diseases.

I write a lot about mast cells and the way they are involved in various other conditions. Mast cells live throughout the body in many tissues. Because they are in so many tissues, their role in many diseases is well researched.

Mast cell activation is not the same as mast cell activation syndrome. I have written about this here. Basically, there are tons of things in the body that cause mast cell activation. These are conditions where we want or need mast cells to become activated because then the mast cells help keep our body working the way it is supposed to. For example, during a woman’s menstrual cycle, if mast cells could not become activated the way they normally do, a woman’s period could become very irregular. This in turn could affect the amounts and types of hormones in a person’s body, causing symptoms and problems.

Situations where mast cells normally become activated include labor and delivery, during any type of infection, during situations where the GI tract is inflamed, when your body is growing new blood vessels, any time your body is healing, and when you have cancer or a tumor. In these situations, the mast cells activate to send signals to other cells in the body to help regulate what is happening. Mast cell activation is not always bad. It is, in fact, a normal and necessary process that happens in the body of everyone every day. Mast cell activation is necessary to stay alive.

Now let’s look at the role of mast cells in diseases that are not mast cell diseases.

When I was little, I was a Girl Scout for three weeks before I got kicked out. (This is true and not related to mast cell activation.) There was a game that we used to play called “Telephone.” During this game, everyone would sit in a big circle. One person would think up a short sentence and whisper it into the ear of the person next to her, who would in turn whisper into the ear of the person next to them, and so on. Often, people misheard the sentence and so it was completely wrong by the time it got back to the person who started it.

Diseases in the human body are like a very complex game of Telephone. In every disease, many cells that did not cause the disease can cause symptoms even though they are not the cause. The way to know if a disease is a true mast cell disease is to know which cell first messed up the sentence in the game of Telephone.

Here’s what this sounds like in people:

Lisa says to Pari: Puff the magic dragon

Pari says to Dana: Puff the magic dragon

Dana says to Celeste: Puff’s magic is dragging

Celeste says to Lisa: Puff’s magic is dragging

So in this situation, Dana changed the sentence. Because she changed it, Celeste also had the sentence wrong. So Dana caused the problem. Celeste did not. (In real life, Dana is lovely and not a problem.)

When your body has a disease, the symptoms and damage are caused by cells giving or receiving messages incorrectly. Instead of using words to talk to each other, cells use molecules. Even though they use molecules to talk to each other, it is very much like a language. If the message is “said” wrong in this cell language, then all the cells after the mistake are doing things that are unhelpful or dangerous. However, they are NOT the cause of the disease because they are not the one that changed the message.

Now let’s look at this with cells in the human body during a disease. I’m going to use a very simplified explanation of rheumatoid arthritis as an example.

T cell says to B cell: I think our body is dangerous to us!

B cell says to T cell: Oh, snap! Let’s get the word out!

B cell needs to tell the body about this danger. It makes a message that says, “Danger right here! Danger!”

B cell says to mast cell: WE ARE IN GRAVE DANGER! ATTACK! ATTACK!

Mast cell to other cells: KILL THIS INVADER KILL IT TO DEATH

Except there is no invader. It is just your regular joints being regular and not dangerous.

Other cells: *trying to kill your joints*

Joints: Uh, guys, I’m actually supposed to be here –

Mast cell: I CAN’T HEAR YOU OVER THIS SCREAMING B CELL

Let’s recap.

T cell gives the B cell bad information. This causes B cell to alert other cells of “danger.” But this wasn’t the B cell’s fault. It was the fault of the T cell which gave the B cell bad information. And that means that everything that comes after the T cell giving the B cell the bad information makes the problem worse but is not really the cause of the problem.

I used rheumatoid arthritis as an example because a lot of treatment of rheumatoid arthritis revolves around blocking those danger signals from mast cells. But is the mast cell the cause of the rheumatoid arthritis? No, it is not. It is not the cause because mast cells have to respond to commands from B cells in order to help protect us against infection and do other helpful things. The mast cell did not decide the joints were dangerous. The B cell told the mast cell this so the mast cell is working with bad information that it doesn’t realize is bad.

If the mast cell isn’t the cause of the rheumatoid arthritis, why do we bother blocking mast cell signals instead of telling the T cell and B cell to be quiet? Because quieting the mast cell signal will help with symptoms and we know how to quiet the mast cell signal and we don’t always know how to quiet the other signals. Stopping the mast cell signal can make symptoms much better but it does NOT cure rheumatoid arthritis. Why? Because mast cells do not cause rheumatoid arthritis.

So mast cells are involved in many diseases without causing most of them. The way you can tell they are not the cause is that they did not start the wrong “message” that caused the symptoms and damage.

Now, I would like to address the fact that there are some diseases that have some research to suggest that they may genuinely be a form of mast cell activation disease. Fibromyalgia is one of these diseases. However, at this time, there is not enough evidence for it to be classified as a mast cell disease.

I tried to be as clear as possible about a very complicated topic. If I didn’t do it well, tell me and I’ll have another go at it.

(Author’s note: This is a SUPER simplified version of rheumatoid arthritis. RA is an autoimmune disease and it is still not clear exactly how the T cells and B cells start sending the wrong messages in an autoimmune disease. I just simplified it here to make it easier to see my point.)

Halloween in my home

Yesterday was a quintessential New England fall day. It was warm and sunny with a little bite to the wind coming off the ocean. Astoria and I walked four miles. I got a bunch of normal people errands accomplished. I drove to go get coffee. It was really lovely.

It was especially lovely because September is tricky for me. The change of seasons hits my mast cells pretty hard. The falling leaves often have mold on them and mold is a huge trigger for me. I always contend with a pretty significant flare in September but it usually wraps up in a week or two. Last year, I deteriorated rapidly in September, ultimately needing months of medical leave. September is making me apprehensive this year.

On top of the physical issues, my last few Septembers have been pretty wrought with emotional stress. I will always associate this time of year with the fever pitch terror of someone you love almost dying and the horror of what happened to Kristina. I imagine I will have difficult Septembers for the rest of my life.

It’s the middle of the night here and I’m awake because I’m in a lot of pain. My abdomen is really swollen and painful. I’m not sure what happened but it’s the same thing that required hospitalization in June. I was sitting at my parents’ house, talking to my dad, and suddenly I was having killer abdominal pain. Like just this side of screaming pain. I took pain meds and extra steroids and mast cell meds but they didn’t do much. So I’m sitting here with a heating pad on my abdomen, waiting.

I am trying to remind myself that eventually it will stop and then I’ll just be in normal pain. That I’ve been in pain a long time but there are days when it is better. But every new pain is an echo of the first one, a lesser shadow that follows closely, a half step behind me. And if it’s all just one unending pain, a red path burned through my life, it doesn’t really ever stop. It might always be like this. I’m hopeful that it won’t but when you are in a lot of pain, it consumes everything. It consumes your happiness and optimism. It consumes your future.

I’m trying to pack my September full of fun plans to get me through. I’m going to a concert this Saturday with my Portland Soul Sisters, Alli and Alyson. I am going apple picking with my nephew. I am going apple picking again with my nieces the weekend after. My nephew’s birthday party is coming up.

Once I get through September, it will be October and I love October. I love Halloween. I watch a different scary movie every night and decorate my house and get a costume together for trick or treating with the kids. Halloween is always the gift I get for surviving September.

I pulled out all my Halloween decorations and decorated my apartment three weeks early. Even if I am in pain forever, I will still get Halloween. So it’s Halloween in my home.

Cobalt

The university I went to had a nuclear reactor. A real one, underground. The radiation source was an unstable isotope of cobalt that glowed an eerie and otherworldly blue at the bottom of a huge pool.

I was a student there a few years before I found out. I walked over it on almost a daily basis.  I had no reason to know it was there until I did and so I didn’t. Naturally, as soon as I found out about the (really woefully and shockingly insecure) nuclear source under my campus, I became very paranoid that it would meltdown or be hijacked by terrorists. I wonder how many hours I have spent worrying about this.

I found out today that a friend of mine has cancer. She told me about her recent appointments and test results. We talked about the grieving process when you receive seriously health news. She hadn’t been having symptoms and the diagnosis took her completely by surprise.

We make a lot of the connection between our minds and bodies. We feel that this linkage is not only real but deeply spiritual, that it is the basis for our awareness of our very selves. We expect there to be signs when something is wrong with our bodies. We feel that we will intuitively known something is off when our bodies harbor such significant health issues. When we don’t, the betrayal is even more searing. We feel that we have failed ourselves in some way and that we have no one to blame but ourselves.

It is harder to reconcile your reality with your experience when the physical state of your body is at odds with your experience of living in it. It makes you wonder what would have happened if you just didn’t know. How many things do we notice only because we know this thing? How many things are significant only because we know this secret hidden inside ourselves? When would you have started to feel sick? Would you ever have noticed otherwise?

I am a scientist and the currency of science is inherently facts and truth. I have always felt it is better to know the facts both in my work and in my health. But it does make me wonder how much time I have lost to perseverating about unlikely worst case scenarios because I demand that knowledge. How much time I have spent being afraid of these things that never came to pass and probably never will? How long have I looked at this shimmering blue and convinced myself of a danger that was never real?

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, Part 59

73. Can mast cell disease cause organ damage?

  • Yes.
  • The term organ damage is tricky because people use it to mean a lot of things while providers and researchers often use it to mean one very specific thing. For providers and researchers, the term “organ damage” usually means a change in the organ that affects its structure, like it becomes misshapen or deformed in some way. Structural changes like this are often irreversible. This damage to the organ’s shape and structure usually affects how the organ works, called organ function.
  • When patients and laypeople talk about organ damage, they usually mean a change in the way the organ functions, even if the structure is not changed at all. This is different in a very important way: changes in an organ that do not affect its permanent structure can sometimes be reversible.
  • Both cutaneous and systemic mastocytosis cause organ damage in a way that damages the organ’s structure. When too many mast cells burrow into the tissue of an organ, it has to push other things out of the way. When you have mastocytosis, the mast cells like to stick together and form a big clump in the tissue. This punches holes in the tissue, affecting the organ’s structure and shape. This is called dense infiltration. It is one of the criteria for systemic mastocytosis and also happens in cutaneous mastocytosis.
  • In patients with mastocytosis, those mast cells clumping together cause a lot of the organ damage. This means that people who have the most mast cells usually have the worst organ damage. Patients with malignant forms of mast cell disease, like mast cell leukemia or aggressive systemic mastocytosis, often have organs that are riddled with TONS of mast cells.
  • Mast cells don’t live in the blood so when your body makes way too many mast cells, those mast cells will dive into whatever organ they can to get out of the bloodstream. This causes damage to the structure that you can see with scans or in biopsies.  People with mast cell leukemia and aggressive systemic mastocytosis suffer so much damage to the shape and function of their organs that the organs can totally stop working, called organ failure.
  • One of the key differences researchers and providers see between mastocytosis and mast cell activation syndrome is that mast cells don’t cause THIS TYPE of structural damage in mast cell activation syndrome patients.
  • We know this because in biopsies, they do not have mast cells clumped together to punch holes in the tissue. Sometimes they have lots of mast cells, but it is much less damaging to the tissue if they aren’t clumped together. Think of it like poking something with finger versus punching with your fist.
  • In MCAS, mast cells do not cause structural damage to organs IN THIS WAY. However, many people with MCAS do have structural damage to their organs. Many of them also have organs that do not function correctly even if the organs look normal.
  • Even if you don’t have mast cells punching holes in all your organs, they can still do a lot of damage. This is because mast cells cause lots of inflammation, which can stress out your organs. Over time, your organs can be damaged by the mast cells releasing too many mediators. While this is not always dangerous, it is certainly painful and frustrating.
  • Many MCAS and mastocytosis patients have a lot of damage to their GI tracts from years of vomiting, obstructions, diarrhea or constipation. Hives and mastocytosis spots can damage your skin, causing discoloration, scarring or sensitivity. Muscles can become weaker over time because of mast cell inflammation. Swelling can stretch out your skin and connective tissues. Nerves can be damaged significantly, affecting organ function. Bones can become brittle and break, or can become too dense because the body is making new bone when it shouldn’t.
  • All of these effects on organ function can be caused by mast cells. Major changes in organ function can also cause secondary conditions to arise.
  • Mast cell patients are also at an increased risk for anaphylaxis which can cause changes in organ function or organ damage.
  • Patients who have trouble breathing or low blood pressure may not be getting enough oxygen to their whole body. That can cause lasting damage if it goes on long enough.

For more detailed reading, please visit the following posts:

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, Part 58

72. How does mast cell disease affect your dental health?

Mast cells are found naturally throughout your body. One of their most important functions is to fight off parasites and infections in your GI tract, starting in the mouth. Everyone has mast cells in their mouth, although most people don’t have a lot of them. They release mediators there like they do everywhere else. For mast cell patients, releasing too many mediators can be a source of symptoms. It causes the oral symptoms many of us experience, including swelling of the lips, mouth and tongue. It can also cause excessive salivation or dryness depending upon the patient.

Your teeth and mouth can be damaged by things that are very acidic. Frequent vomiting as a result of mast cell disease (or anything) can really damage your teeth. It erodes the protective coating over your teeth. It is very hard to effectively wash all the acid out of your mouth after vomiting as it can collect at or below the gumline. This is the reason I personally have had some dental issues in the last few years. Even though I was very diligent about brushing after vomiting, I couldn’t brush beneath the gums to prevent formation of cavities.

My dentist recently recommended that I neutralize the acid in my mouth before brushing instead of brushing immediately after vomiting. Brushing your teeth with acid in your mouth spreads it around your teeth and causes little craters to form on your teeth. My dentist recommended I rinse my mouth out with water and baking soda to neutralize the acid before brushing after I vomit. I also use a prescription toothpaste to help keep my teeth strong. (Always consult your own care team about specific steps you can take before changing your care plan.)

Redness and burning in the mouth can be the result of mast cell activation. For mast cell patients, this can be worsened by exposure to triggers, especially triggers you ingest.

Gum health can be tricky for mast cell patients. For those of us with connective tissue diseases like Ehlers Danlos, we are always at a disadvantage. My old dentist used to constantly give me crap about not flossing even I flossed regularly. This was years before I knew I had EDS and that patients with EDS often have bleeding gums regardless of flossing. Bleeding of any kind activates mast cells, so if you bleed when you brush your teeth, that can be a trigger.

Having swollen or bleeding gums makes it easier for you to get infections in your mouth. Even more seriously, it makes it much easier for infectious organisms to be transferred from your mouth into your bloodstream, where they can cause an infection. This is exactly what happened to me in March 2016 when I had the Danger Tooth pulled. This is a concern for anyone but especially people who have central lines. When you have a central line, bugs that end up in your bloodstream can stick onto your central line and grow more quickly. As this line ends just above your heart, line infections can be very serious, even if they started in the mouth and not the line itself. Sometime dentists treat patients with antibiotics before dental care to avoid this, but it is very patient specific.

Dental cleanings use lots of materials or meds that can trigger mast cell degranulation. A lot of them have extra junk in them, like dyes or flavors. Vibration and scraping during the cleaning can be triggering. Many mouth washes are off limits for us, especially those with dyes and alcohols. And of course, dental work can be painful or cause bleeding which is problematic for us. Anxiety is also common.

I personally do okay with the plain grey pomice scrub for cleanings. Mast cell patients should premedicate before any procedures, including detail appointments. See the link below for the premedication recommendations for mast cell patients.

Dental procedures or surgeries have the same problems as cleanings but to a stronger degree. Installing permanent or semipermanent hardware into the mouth carries the risk of later reacting to it. Braces, retainers and splints can be super tricky for us. The decision to put in a crown or something similar should involve the mast cell specialist on your care team. I personally have opted to have a tooth pulled rather than run the risk of later reactions to the crown.

Numbing medications can be mast cell triggers, like some of the –caine anesthetics. Sometimes dentists will use a preparation of anesthetic that also has a little epinephrine in it to help control the bleeding. While I personally do not have problems with this preparation, a lot of mast cell patients do because it contains a preservative.

For more detailed reading, please visit the following posts:

The Provider Primer Series: Medications that impact mast cell degranulation and anaphylaxis

Premedication and surgical concerns in mast cell patients

 

The MastAttack 107: The Layperson’s Guide to Understanding Mast Cell Diseases, Part 57

71. What other diseases “look like” mast cell disease?

Mast cell diseases have many symptoms that are also commonly found in other disorders. This is one of the reasons why it is difficult to diagnose correctly. The following conditions have symptoms that can look like mast cell disease.

Neuroendocrine cells are specialized cells that help to pass signals from the nervous system to nearby cells, causing those cells to release hormones. There are many types of neuroendocrine tumors. Some conditions that look like mast cell disease are caused by these tumors. Symptoms from them are caused by the response of too much hormone.

Carcinoid syndrome is the result of a rare cancerous growth called carcinoid tumor. This tumor releases too much serotonin into the body. This can cause flushing, nausea, vomiting, diarrhea, difficulty breathing, and cardiovascular abnormalities such as abnormal heart rhythm. Mast cells also release serotonin but they release much less than carcinoid tumors.

VIPoma means vasoactive intestinal peptide –oma. When a word has –oma at the end, it means that it is a tumor. A VIPoma is a tumor that starts in the pancreas. It releases a chemical called vasoactive intestinal peptide. VIPoma can cause flushing, low blood pressure, and severe diarrhea leading to dehydration. A VIPoma can also abnormalities in the composition of the blood. Many patients have low potassium, high calcium, and high blood sugar.

Pheochromocytomas start as cells in the adrenal glands. They release excessive norepinephrine and epinephrine. They can cause headaches, heart palpitations, anxiety, and blood pressure abnormalities, among other things.

Zollinger-Ellison syndrome is a condition in which tumors release too much of a hormone called gastrin into the GI tract. This causes the stomach to make too much acid, damaging the stomach and affecting absorption.

Some blood cancers can cause mast cells to become overly activated. They may also cause an increase in tryptase, an important marker in diagnosing systemic mastocytosis.

Some other cancerous tumors like medullary thyroid carcinoma can cause mast cell type symptoms including flushing, diarrhea, and itching.

Most diseases with any allergic component can look like mast cell disease.

Eosinophilic gastrointestinal disease occurs when certain white blood cells called eosinophils become too reactive, causing inflammation to many triggers. Furthermore, people are more frequently being diagnosed with both EGID and mast cell disease.

Celiac disease is an autoimmune disease in which gluten causes an inflammatory reaction inside the body. The damage to the GI tract can be significant. Malabsorption is not unusual. Children with celiac disease may grow poorly. Bloating, diarrhea, ulceration, and abdominal pain are commonly reported.

FPIES (food protein induced enterocolitis syndrome) can cause episodes of vomiting, acidosis, low blood pressure and shock as a result of ingesting a food trigger.

Traditional (IgE) allergies can also look just like mast cell disease. They are usually distinguished by the fact that mast cell patients may react to a trigger whether or not their body specifically recognizes it as an allergen (does not make an IgE molecule to the trigger). Confusingly, it is possible to have both traditional IgE allergies and mast cell disease.

Postural orthostatic tachycardia syndrome (POTS) is commonly found in patients with mast cell disease. However, POTS itself can have similar symptoms to mast cell disease. Palpitations, blood pressure abnormalities, sweating, anxiety, nausea, and headaches are some symptoms both POTS and mast cell disease have. There are also other forms of dysautonomia which mimic the presentation of mast cell disease.

Achlorhydria is a condition in which the stomach does not produce enough acid to break down food properly. This can cause a lot of GI pain, malabsorption, anemia, and weight loss.

Hereditary angioedema and acquired angioedema are conditions that cause a person to swell, often severely. Swelling may affect the airway and can be fatal if the airway is not protected. Swelling within the abdomen can cause significant pain and GI symptoms like nausea and vomiting.

Gastroparesis is paralysis of the stomach. People with GP often experience serious GI pain, vomiting, nausea, diarrhea or constipation, bloating and swelling.

Inflammatory bowel diseases and irritable bowel syndrome can all cause GI symptoms identical to what mast cell patients experience.

This list is not exhaustive. There are many other diseases that can look similar to mast cell disease. These are the ones I have come across most commonly.

For more detailed reading, please visit the following posts:

Gastroparesis: Part 1
Gastroparesis: Treatment (part 2)
Gastroparesis: Diabetes and gastroparesis (Part 3)
Gastroparesis: Post-surgical gastroparesis (Part 4)
Gastroparesis: Less common causes (Part 5)
Gastroparesis: Autonomic nervous system and vagus nerve (Part 6)
Gastroparesis: Idiopathic gastroparesis (Part 7)

Food allergy series: Food related allergic disorders
Food allergy series: FPIES (part 1)
Food allergy series: FPIES (part 2)
Food allergy series: Eosinophilic colitis
Food allergy series: Eosinophilic gastrointestinal disease (part 1)
Food allergy series: Eosinophilic gastrointestinal disease (part 2)
Food allergy series: Eosinophilic gastrointestinal disease (part 3)
Food allergy series: Eosinophilic esophagitis (Part 1)
Food allergy series: Eosinophilic esophagitis (Part 2)
Food allergy series: Eosinophilic esophagitis (Part 3)

Angioedema: Part 1
Angioedema: Part 2
Angioedema: Part 3
Angioedema: Part 4

Deconditioning, orthostatic intolerance, exercise and chronic illness: Part 1
Deconditioning, orthostatic intolerance, exercise and chronic illness: Part 2
Deconditioning, orthostatic intolerance, exercise and chronic illness: Part 3
Deconditioning, orthostatic intolerance, exercise and chronic illness: Part 4
Deconditioning, orthostatic intolerance, exercise and chronic illness: Part 5
Deconditioning, orthostatic intolerance, exercise and chronic illness: Part 6
Deconditioning, orthostatic intolerance, exercise and chronic illness: Part 7