Haemophilia, Hemophilia

Hemophilia is a bleeding disorder that occurs almost exclusively among boys and men. Currently hemophilia is not curable, but most cases of it can now be treated effectively. Although it is an inherited condition that can be detected before a child is born, hemophilia is usually discovered when a small child who is beginning to crawl suffers exaggerated bruising from what ordinarily would be minor injuries. While most people think of bleeding from open wounds when they think of hemophilia, external injuries do not usually present the most serious problem. Uncontrolled internal bleeding is much more dangerous. Internal bleeding close to the skin surface causes bruises; bleeding into deeper tissues may result in a hematoma, which is a pocket of blood inside a muscle or organ. Individuals with hemophilia not only tend to have more bruises than other individuals, their bruises are usually more severe. Something as simple as a shot that is injected into muscle tissue may cause a large bruise that lasts for several weeks.

In the late 1800s and early 1900s, hemophilia was sometimes called "The Royal Disease", because many members of the English, German, Russian and Spanish royal families either had it or carried it. Until the 1960's, when clotting factors were identified, the only treatment for hemophilia was blood transfusions. Unfortunately, not enough of the needed clotting factors are present in whole blood or blood plasma to stop serious internal bleeding, so most individuals with severe hemophilia died before reaching adulthood. Others suffered painful and disabling joint damage. Today, because hemophilia can be controlled with clotting factor products, most individuals who have it lead nearly normal lives. Excellent resources, including support groups, are available for individuals with hemophilia and their families. Research, especially in the field of gene therapy, offers hope for better treatment and even a cure in the not-too-distant future.

What is it?

Hemophilia is a disorder of the blood clotting system. Normally, an injury to a blood vessel activates certain blood components known as “clotting factors”. A series of 12 natural clotting factors helps to change ordinary blood components into sticky clumps. Platelets, tiny cell particles that circulate in blood, begin attaching to each other and to protein fibers that are also in the blood. Ordinarily, a soft mass of platelets and fibers (a blood clot) forms quickly, bleeding stops, and the wound begins to heal. This process is known as coagulation. Hemophilia results when one or more clotting factors are absent or insufficient. As a result, either blood clots break apart because they are too fragile to withstand blood flow or clots do not form, at all.

Although a deficiency of any of the 12 clotting factors is possible, the two that appear to be most essential to forming blood clots are factor 8 (designated by the Roman numeral VIII) and factor 9 (IX). A deficiency of factor VIII is also called hemophilia A or classic hemophilia. Approximately 80% of individuals with hemophilia have hemophilia A. Abnormal production of factor IX is called hemophilia B or Christmas Disease (because the first person diagnosed with it was named Stephen Christmas). About 10% to 15% of individuals with hemophilia have hemophilia B. Other inherited bleeding disorders, including deficiencies of other clotting factors and von Willebrand's disease, are very rare.

Both hemophilia A and hemophilia B are classified by the estimated percentage of natural clotting factor that is produced by the individual.

Mild hemophilia is considered to be 5% of normal production

Moderate hemophilia is 1% to 5% of normal production

Severe hemophilia is 1% or less

About two-thirds of individuals with hemophilia A and about half with hemophilia B have severe cases. The severity of an individual’s condition often corresponds to the likelihood of physical problems. It may also predict how serious those problems might be and suggest which treatments may be most effective.

Although most bleeding episodes in mild to moderate hemophilia usually result from an injury, individuals with severe hemophilia may experience bleeding with no apparent cause. In severe hemophilia, most bleeding is internal. Bleeding may occur inside joints and muscles, or more seriously, in organs such as the stomach or brain. However, if the appropriate clotting factor is given as quickly as possible following injury, individuals with hemophilia may not have either visible evidence of bleeding or interference with everyday life.

The physical damage that can result from untreated serious bleeding depends on where the bleeding occurs.

• Serious bleeding into muscle tissue: Areas of muscle cells around the bleeding may die. The resulting scar tissue contracts as it is formed, potentially leading to decreased ability to bend joints. The scar tissue may also squeeze nerves, causing numbness and tingling.
• Serious bleeding into joints: Knees, elbows, ankles, shoulders, hips, and wrists, are usually affected in that order. Joint bleeding may cause multilayered damage that may result in severe, painful arthritis. Commonly, damage progresses as follows:
  • Blood flows into the joint until pressure in the joint space increases significantly, shutting off the flow of blood.
  • Bone ends in the joint are forced apart by the extra blood, causing pain and swelling,
  • Red blood cells release iron and other compounds as they break down within the joint space. Both the resulting debris and the scavenger cells that enter the joint to remove it, attack the smooth cartilage at the ends of the bones.
  • Eventually, patches of cartilage erode away, softened areas of bone splay out, and small areas of dead bone form cysts. Ligaments stretch and slacken, allowing bones to shift into unnatural positions. Chronic handicaps may develop. Hemophilic arthritis can lead to muscle wasting. Weakened bones also increase the risk of fractures.
• Bleeding into the skull or brain: Because bleeding can press on the brain, drowsiness, extreme headaches, nausea, vomiting, and sensitivity to light may result. Scar tissue, which can also be caused by bleeding into the brain, occasionally leads to epilepsy.

Gastroesophageal Reflux Disease (GERD) -

Commonly called heartburn or indigestion, GERD is a sense of burning and discomfort between the ribs just below the sternum (breastbone). Sometimes people with GERD experience a sour or bitter taste in the back of their mouth or throat

What causes it?

The esophagus is the passageway ("food pipe") that carries swallowed food to the stomach. GERD occurs when the muscular valve between the esophagus and the stomach does not function properly, causing acid to back up into the esophagus. The acid can then cause inflammation of the esophagus (esophagitis). GERD can cause internal bleeding or esophageal ulcers.

Chronic GERD can result in:

• narrowing of the esophagus from chronic scarring, making it difficult to completely swallow
• a condition known as Barrett's esophagus, which is sometimes a precursor to esophageal cancer
• Mechanism of GERD

Who has it?
Heartburn, the primary symptom of GERD, affects about seven per cent each day. The prevalence increased in adults older than 40 years of age. In addition, up to 25 percent of pregnant women have heartburn on a daily basis because of increased pressure from the uterus pushing up on the stomach. Since other disorders can cause heartburn (e.g., peptic ulcer disease), less people are found to actually have GERD. It is estimated that approximately 10% of Americans suffer from heartburn daily and more than one-third have occasional symptoms.

Because most patients with GERD require chronic therapy, costs associated with diagnosis and treatment are estimated to be $9.3 billion.

Hepatitis C - Causes

What causes it?

Why HCV attacks liver cells is not well understood, but liver damage may be caused in at least three possible ways:

1. Direct cell damage. Viral cells are parasites that depend on normal cells to multiply. Once a virus enters a normal cell, the virus uses the cell’s DNA to make more virus, which is released when the normal cell dies. While other viruses are more likely to infect other body cells, HCV affects liver cells.
2. The development of immune complexes in the liver. Proteins that are formed by the body’s immune system to get rid of the virus, immune complexes may also cause damage to liver cells.
3. The action of T-cells. Specialized white blood cells that attack and kill substances identified by the body as invaders, T-cells may destroy liver cells instead of HCV because the virus is changing so quickly.

Headaches - Types of Headache

Tension Headache

The most common type of headache, tension headache pain is usually described as feeling like a tight band that puts constant pressure on both sides of the head. Pain may extend into the neck or shoulders. Generally, tension headaches are mild to moderate in severity and they do not usually interfere with routine activity. An occasional inconvenience for most individuals, tension headaches often have a specific cause such as fatigue or stress. However, some individuals may have frequent or even daily tension headaches that may be severe enough to limit regular activity. Chronic tension headaches may have no apparent cause or they may be associated with other conditions such as anxiety, depression, or insomnia. About equal numbers of men and women have tension headaches and individuals of any age may experience them, although they most commonly occur between the ages of 20 and 40 years.

Migraine Headache

Migraine headaches are often described as intense throbbing or pounding pain on one or both sides of the head. Nausea and the inability to tolerate light, smells, or sounds may accompany the pain of a migraine. Up to a third of individuals who have migraines may have a warning that a migraine is about to start. These individuals may experience an aura that may include visual changes (such as dimmed or blinking lights) or unusual sensations (such as tingling in their hands, feet, or face). Generally, migraines are infrequent, although they may be chronic for some individuals. Migraines can last for days, often leaving patients feeling exhausted and lethargic. While the exact causes of migraine headaches are unknown, individuals who have recurring migraines may be able to identify physical factors that “trigger” their migraines. For example, some migraines are attributed to stress; others may occur in response to environmental changes, such as very cold weather; certain foods may contribute to other migraines. About three times as many women as men suffer from migraines, with many women experiencing migraines around their menstrual periods.

Cluster Headache

Much less common than migraines or tension headaches, cluster headaches usually occur in groups (clusters) that may continue for a few days up to several weeks. Most often cluster headaches involve sudden attacks of extreme pain lasting from a few minutes to several hours and often involving only one side of the head. Affecting many more men than women, cluster headaches may be associated with irritation of the eye and nose. Individuals who smoke and drink alcohol may be more prone to having cluster headaches. This type of headaches are more prone in people who have the following: people with eye problem, runny noses, facial sweating.

Other Types of Headaches

Organic Headache

Organic headaches are relatively rare, but they need immediate medical attention because they have serious physical causes such as blood clots, brain tumors, brain infections, or bleeding into the brain. Sometimes becoming intensely severe over a few hours or days, they may be associated with weakness, confusion, or unconsciousness.

Sinus Headache

Usually, sinus headache pain is due to swelling in the sinus cavities around the nose and eyes. Often caused by allergies or infections, sinus headaches may be accompanied by fever, a stuffy nose, or toothaches. Leaning forward or lying down may increase sinus headache pain.

Rebound Headache

Ironically, rebound headaches result from overuse of headache medications. Individuals who take more headache medication than recommended, take it continually for long periods of time, or consume large amounts of caffeine may need more and more medication to control headache pain. When the effects of the medication start to decrease, the headache is even worse and more medication is needed. Eventually, the medication doesn’t work anymore. Individuals who have ten or more headaches a month may be experiencing rebound headaches.

Hormonal Headache

Headaches of the hormonal type often result from fluctuation of hormones in the female body.

Hepatitis

Introduction

The word "hepatitis" means inflammation of the liver. Rarely, some kinds of hepatitis are not caused by infection. These non-contagious types of hepatitis can result from alcohol abuse, certain drugs, ingestion of toxic substances, or autoimmune disease (the body's own immune system attacks the liver). The usual cause of hepatitis, however, is infection by a virus. At least six viruses, usually identified by the letters A through G, are known to cause hepatitis. In the United States, hepatitis A, hepatitis B, and hepatitis C are the most common.

Typically, hepatitis B and hepatitis C infections have distinct phases. The first, or acute phase, occurs soon after infection with the hepatitis virus and lasts for 6 months or less. Many individuals recover from acute hepatitis, and their livers return to normal within a few months. Depending on the type of hepatitis, however, some of the individuals who contract acute hepatitis infections may not be able to eliminate the virus. For these individuals, the acute infection may be followed by a chronic phase. Usually, chronic hepatitis involves a prolonged latent or inactive period. During this time, which may last 20 years or longer, individuals with hepatitis probably do not experience symptoms or feel ill. Generally, however, the virus continues to multiply, gradually causing liver damage. Typically, symptoms do not become apparent until liver damage is extensive. However, abnormal levels of liver enzymes such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST) may show if liver tests are done.

What is it?

Hepatitis B is a specific type of hepatitis caused by the virus that has been designated as hepatitis B virus (abbreviated as HBV), which causes inflammation and damage to the liver. As the virus infects more liver cells, inflammation and destruction of liver cells can interfere with the functions of the liver.

Normal Liver Functions That May Be Affected by Liver Damage
Breakdown of harmful substances to keep them from building up in the bloodstream
Production of bile to help digest food
Production of cholesterol and protein
Regulation of blood clotting
Storage and release of energy in the form of sugar

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Most individuals are able to fight off (or clear) infection with HBV and they recover in 2 to 4 months. Ordinarily individuals only get hepatitis B once and after the HBV infection has been cleared, the individual has lifelong immunity . Up to 10% of adults, 50% of children under the age of 5, and 90% of infants who contract hepatitis B will not be able to eliminate the virus in 6 months. These individuals are considered to be chronic carriers of HBV.

It is estimated that chronic hepatitis B affects 1.25 million people in the United States and leads to 5,000 U.S. deaths per year. Chronic hepatitis puts individuals at a greater risk of developing cirrhosis or liver cancer. Cirrhosis is a condition that gradually replaces active liver cells with inactive scar tissue. Slowly, liver function is lost and liver failure may result. However, individuals who are chronic carriers of HBV but who have no symptoms are much less likely to develop cirrhosis than individuals who have chronic symptoms of hepatitis B.

Hepatitis C - Risk Factors - Who gets Hepatitis C?

Who has it?

The World Health Organization estimates that 180 million people around the world (about 3% of the population) are infected with HCV. Although it affects members of all ethnic groups, hepatitis C appears to be more common in less industrialized areas of the world, with estimates as high as 20% of the population in some countries.

According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 4.1 million Americans (about 1.6% of the population) show evidence of having had an infection with HCV. Only about 25% of those individuals experienced symptoms that were attributed to hepatitis C, but 55% to 85% of them went on to the chronic phase. The Center for Disease Control estimates that there are 26,000 new infections each year, a decrease from the average of 240,000 per year in the 1980s. Most will develop chronic liver disease, which may progress to cirrhosis or liver cancer. In the 1970s and 1980s, a number of individuals got hepatitis C from donated blood that was contaminated with HCV, Today, the risk of transfusion-associated hepatitis C is very low (approximately one chance for every 100,000 units that are transfused). Approximately 25% of people who have HIV/AIDS will develop hepatitis C. Persons with HIV are more prone to get hepatitis C through sexual exposure.

What are the risk factors?

Mainly, HCV is passed from one individual to another through blood and blood products. A much smaller chance exists that it may also be transferred in bodily secretions, such as semen. The risk for infection with HCV is increased for individuals who:

• are born to mothers who have HCV
• had contact with high-risk individuals more than 6 months before the onset of symptoms
• have ever injected street drugs (even only once or many years ago)
• have HIV or AIDS
• have sexual contact with an infected individual
• live in poor socioeconomic conditions
• received transfusions of blood or blood products (especially before July 1992)
• require long-term kidney dialysis
• used blood-derived clotting factors before 1987
• work in health care facilities where they may be exposed to blood
• have liver disease

Illegal injection drug use accounts for about 60% of new HCV infections in the United States. In approximately 10% of infections, the source of exposure is unknown.

High Cholesterol - what does it mean?

With cholesterol testing at health fairs and drug stores, and with a breakdown of fat and cholesterol counts on all the packaged food we eat, you are probably well aware of the relationship between high cholesterol and heart disease. Yet, heart disease remains the leading cause of death in the United States; and you may not always eat the healthy, low-cholesterol diet that you should.

Because of the important relationship between high cholesterol and heart disease, all adults over the age of 20 years should have a fasting lipoprotein profile [a complete cholesterol profile--includes measuring total cholesterol, triglycerides, low-density lipoprotein(LDL) and high-density lipoprotein (HDL)] checked at least every 5 years. This should occur more often if a family history of coronary heart disease exists. Most children do not need to have their blood cholesterol level checked.

Hepatitis - Treatments

How is it treated?

Hepatitis B that lasts beyond 6 months or becomes serious may be treated with several different medications, but not every case needs to be treated. Whether or not an individual with hepatitis B is taking medication, regular visits to a doctor who specializes in liver diseases are very important. Laboratory tests that measure liver function, need to be performed regularly to track disease progression and to determine possible complications. Because no cure has been found for hepatitis B, treatment is aimed at decreasing the ability of the virus to multiply, decreasing inflammation and damage to the liver, and increasing the immune system’s ability to fight the virus.

Currently, drug treatments seem to be most helpful for individuals who have liver disease caused by hepatitis B. Unfortunately, there is no drug treatment for the acute phase of hepatitis B. Nausea and vomiting often seen with early infection is treated with fluid replacement. In the United States, the four drugs that have been approved by the Food and Drug Administration (FDA) for treating chronic hepatitis B are:

Interferon-alpha (Intron A and Pegasys) A synthetic version of antiviral proteins produced by the immune system, artificial interferon is used to treat a number of conditions. Although it may cause side effects such as depression, headache and flu-like symptoms, interferon is approved for both children and adults with hepatitis B. It is given by injection several times a week. There is also a modified form of interferon known as peginterferon that has been approved for the treatment of Hepatitis B and C. It has a similar but larger chemical structure than interferon-alpha that improves how the drug works and only needs to be injected once weekly.

Lamivudine (Epivir-HBV) Taken orally once a day for at least a year, lamivudine is approved for use by both children and adults with chronic hepatitis B. It has very few side effects, but long term use of lamivudine is likely to cause the hepatitis virus to become resistant to the effects of this medicine. Because of this, combination therapy and the use of other medicines to treat hepatitis B are areas of intense study.

Adefovir dipivoxil (Hepsera) Approved only for adults with chronic hepatitis B, adefovir is taken once a day as an oral tablet. Studies have shown that use of adefovir has been beneficial in reducing the amount of virus in the body without causing as much resistance as lamivudine. The most common side effects experienced by patients taking this medicine are headache, throat pain, and stomach pain.

Entecavir (Baraclude) Approved by the FDA March 30,2005, entecavir resembles a product needed by viral DNA to continue growing. It has been approved for chronic hepatitis B patients in whom the virus is active and replicating. Entecavir can also be used in patients with a resistant virus who have failed lamivudine therapy. Entecavir, taken as an oral tablet or solution once daily, is tolerated as well as lamivudine. The hepatitis B virus is much less likely to develop resistance to entecavir, representing a convenient treatment option for chronically infected patients.

Therapy with one drug is still considered to be the first line treatment approach and the choice of drug is specific to each patient with chronic hepatitis B. Combination therapy with interferon alpha and a nucleoside analog (like lamivudine or entecavir) may be used to prevent viral resistance and has shown promising results in reducing viral replication. However, further studies are needed to fully evaluate the benefit of combination therapy over treatment with one drug. Your doctor may run tests to check the health of your liver if you are on medicines like adefovir, lamivudine, or entecavir. If you are on any of these medicines, tell your doctor if you experience abdominal pain, skin discoloration, orange or dark urine, and frequent diarrhea or constipation.

Prevention of hepatitis B

Hepatitis B cannot be cured, but it can be prevented relatively easily.

Before exposure to HBV

The hepatitis B vaccine (Engerix-B, Recombivax HB) is a safe and effective protection from hepatitis B. Given as three injections during a 6-month period, it generally produces immunity for 15 years or longer. Generally, the injections are given in a doctor’s office or clinic.

Currently, hepatitis B vaccination is required by many school districts before a student is admitted. It is recommended for all individuals under the age of 19 years and for individuals who:

• are homosexual men
• have kidney dialysis
• have liver diseases (including other types of hepatitis)
• have multiple sex partners
• have or ever have had a sexually transmitted disease (for example, gonorrhea or syphilis)
• have sex with a partner who has hepatitis B
• have sex with multiple partners
• live in or travel to countries where hepatitis B is common
• live in the same home as an individual who has chronic hepatitis B
• may be exposed to HVB in blood

After exposure to the virus

Individuals who know or believe that they have been exposed to HBV, including babies born to mothers who test positive for HBV, should receive the three hepatitis B vaccine injections. They should also get one injection of hepatitis B immune globulin (BayHep B, Nabi-HB). Abbreviated as HBIG, this medication is made up of immune system proteins that specifically help to fight HBV.

Drug classes used to treat Hepatitis B

Interferons

Nucleoside Reverse Transcriptase Inhibitors

Celiac Disease

Celiac (coeliac) disease is a chronic condition where the body reacts to a protein — called gluten — and loses its ability to absorb necessary nutrients. Gluten is most commonly found in wheat, barley, rye, and oats. Celiac disease is considered an auto immune disorder because with consumption of gluten, the immune system actually attacks the body’s own cells in the small intestine.

The exact cause of celiac disease is unknown. Research has shown that it may have a genetic link, and the disease usually appears after some distress to the body such as pregnancy, childbirth, illness, severe emotional stress, physical injury, or surgery.

The effects of celiac disease appear when a protein, called gluten, is consumed. The small intestines are responsible for proper absorption of nutrients needed for energy and building of body tissues. Tiny projections, called villa, line the small intestines to allow greater absorption of food and nutrients. When gluten enters the small intestine, a reaction occurs and the body attacks the villa, leaving small lesions. Upon damage to the villa, the small intestine is then unable to absorb nutrients properly leading to symptoms of malnourishment.

Gout

Gout is a type of arthritis (inflammation of the joints) that mostly arises in men age 40 years and older. Women can also develop gout, although it is more likely to occur after menopause. Gout is caused by a buildup of needlelike uric acid crystals in the joints. Uric acid is a waste product in your body that comes from two sources:

1. Normal cell metabolism
2. Digestion of the food you eat

Under normal conditions, most uric acid is passed through the kidneys and is eventually excreted in the urine. There is a small amount of uric acid in your blood at all times, which does not cause problems. However, in patients with gout, the amount of uric acid in the blood is higher than normal, either because their body produces too much uric acid or because their kidneys are unable remove uric acid from the blood. The excess amount of uric acid in individuals with gout is stored in the joints and over a period of time may result in crystal formation. The uric acid crystals deposited in the joints are responsible for the excruciating pain of gout.

There are two types of gout, primary and secondary, depending on the cause of high uric acid in the blood.

Primary Gout: Primary gout is the most common. In primary gout the cause of excess uric acid is usually not known. Most scientists believe that primary gout is caused by genetics, which means that patients probably inherited this condition from someone in their family. The basic defect is either an impaired clearance of uric acid by the kidneys (also termed "underexcreter"), an increase in production of uric acid (termed "overproducer"), or a combination of both defects.

Secondary Gout: In secondary gout, the cause of excess uric acid is usually known. Most commonly, secondary gout is caused by certain medications or health conditions.

Medications that may cause secondary gout include:

• Diuretics ("water pills"), such as chlorothiazide (Diuril), chlorthalidone (Hygroton), hydrochlorothiazide (Esidrix, HCTZ, HydroDIURIL, Oretic), metolazone (Mykrox, Zaroxolyn), bumetanide (Bumex, Edecrin), ethacrynic acid, furosemide (Lasix), torsemide (Demadex)
• Pyrazinamide (PZA)
• Cyclosporine (Sandimmune, Neoral)
• Aspirin
• Nicotinic acid (Niacin)
• Levodopa

Health conditions that may cause secondary gout include:

• Alcoholism
• Leukemia
• Lymphoma
• Lung cancer
• Smoking
• Psoriasis
• Obesity
• Kidney dysfunction
• Congestive heart failure
• Starvation
• Anemia
• Untreated high blood pressure
• Diabetes
• Severe illness or injury
• Immobility due to bed rest
• Down's syndrome
• Thyroid disorders

Glaucoma

Glaucoma is an eye disease that is caused by an increase in intraocular pressure (IOP) -- this pressure gives the eyeball its round shape. The increase in IOP results from a change in the eye's ability to drain aqueous humor, the fluid circulating inside the eye.

There are two general types of glaucoma: -open-angle and closed-angle (the angle refers to the point where the muscles that keep open the pores that drain the fluid meet.)

The most common type is open-angle glaucoma (accounts for 90% of glaucoma cases); it is the leading cause of blindness in people of African American descent. Normally, open-angle glaucoma is a slowly progressive (or chronic) disease that produces no obvious symptoms until its late stages and occurs in both eyes, although one eye may have a faster progression of the disease than the other. A smaller percentage of people develop closed-angle glaucoma, which is typically acute (occurs more suddenly) and associated with a red, swollen, and painful eye. It is usually the result of a blockage of the pores that drain eye fluid and should be treated urgently to remove the blockage to help avoid permanent vision loss.

Fibromyalgia

Fibromyalgia (FM) is a chronic pain disorder that affects the muscles and the soft fibrous tissues of the body (the ligaments, tendons, and soft tissue in between joints). The word 'fibromyalgia' comes from the Latin words for fibrous tissue (fibro), muscle (myo), and pain (algia). Unlike other chronic painful diseases (e.g. multiple sclerosis), FM is a syndrome. A syndrome is a loose collection of signs and symptoms that characterize a condition. Unlike a disease, the exact cause of FM is still unknown. People with fibromyalgia have 'tender points' on the body. Tender points are specific places on the body especially the neck, shoulders, back, hips, arms, and legs. These points hurt when pressure is put on them. Too much exercise or overexertion of muscles can make FM symptoms worse, as can physical inactivity. FM is very hard to diagnose. Patients often experience many signs and symptoms that vary in amount and intensity and can be easily confused with other conditions. This confusion can increase the pain and frustration often felt by a patient with FM.