Tag Archives: M.E./C.F.S.

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Canadian Clinical Working Case Definition of ME/CFS

I don’t understand why the United States does not acknowledge myalgic encephalomyelitis. The Merck Manual doesn’t even mention it and the symptoms and recommendations for chronic fatigue syndrome are not the same as for M.E. Canada, Australia and the UK seem to be light-years ahead in their acknowledgement of this disease, if not their treatment (but probably that, too).

The “Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols” written in Canada by Dr. Bruce Carruthers et al. is excellent. It says, “As the CDC definition was primarily created to standardize research, it may not be appropriate to use for clinical diagnoses, a purpose for which it was never intended. There has been a growing demand within the medical community for a clinical case definition for ME/CFS for the benefit of the family physician and other treating clinicians. The CDC definition, by singling out severe, prolonged fatigue as the sole major (compulsory) criterion, de-emphasized the importance of other cardinal symptoms, including post-exertional malaise, pain, sleep disturbances, and cognitive dysfunction. This makes it more difficult for the clinician to distinguish the pathological fatigue of ME/CFS from ordinary fatigue or other fatiguing illnesses.” This makes me want to punch the CDC in the face. This is why my visit to what I thought was the Chronic Fatigue SYNDROME Clinic turned out to be just the Chronic Fatigue Clinic — for all fatigue. For people who don’t sleep, people who are depressed, people who are overweight and don’t exercise, people with other fatiguing diseases. Eat pizza because your blood pressure is low, eat turkey because you don’t sleep well, get massages because your muscles hurt. Idiotic advice. Thanks, I’ve been on the waiting list for months, feeling like I’m dying a slow, uninformed death and that’s the best you’ve got? I’m still irritated. Actually, I’m outraged. But I’ve bitched about that enough in other posts.

Let’s look at the Clinical Working Case Definition of ME/CFS from the article above:

1. Fatigue: The patient must have a significant degree of new onset, unexplained, persistent, or recurrent physical and mental fatigue that substantially reduces activity level. CHECK
2. Post-Exertional Malaise and/or Fatigue: There is an inappropriate loss of physical and mental stamina, rapid muscular and cognitive fatigability, post exertional malaise and/or fatigue and/or pain and a tendency for other associated symptoms within the patient’s cluster of symptoms to worsen. There is a pathologically slow recovery period–usually 24 hours or longer. CHECK
3. Sleep Dysfunction:* There is unrefreshed sleep or sleep quantity or rhythm disturbances such as reversed or chaotic diurnal sleep rhythms. CHECK
4. Pain:* There is a significant degree of myalgia. Pain can be experienced in the muscles and/or joints, and is often widespread and migratory in nature. CHECK Often there are significant headaches of new type, pattern or severity. CHECK
5. Neurological/Cognitive Manifestations: Two or more of the following difficulties should be present: confusion, impairment of concentration CHECK and short-term memory consolidation, disorientation, difficulty with information processing, categorizing and word retrieval, CHECK and perceptual and sensory disturbances–e.g., spatial instability and disorientation and inability to focus vision. CHECK Ataxia, muscle weakness and fasciculations are common. CHECK There may be overload phenomena: cognitive, sensory–e.g., photophobia CHECK and hypersensitivity to noise CHECK–and/or emotional overload, which may lead to “crash” periods and/or anxiety. CHECK
6. At Least One Symptom from Two of the Following Categories:
a. Autonomic Manifestations: orthostatic intolerance–neurally mediated hypotenstion (NMH), CHECK postural orthostatic tachycardia syndrome (POTS), CHECK delayed postural hypotension; light-headedness; CHECK extreme pallor; nausea and irritable bowel syndrome; CHECK urinary frequency CHECK and bladder dysfunction; palpitations with or without cardiac arrhythmias; CHECK exertional dyspnea. CHECK 
b. Neuroendocrine Manifestations: loss of thermostatic stability– subnormal body temperature and marked diurnal fluctuation, CHECK sweating episodes, CHECK recurrent feelings of feverishness CHECK and cold extremities; CHECK intolerance of extremes of heat and cold; CHECK marked weight change–anorexia or abnormal appetite; loss of adaptability and worsening of symptoms with stress. CHECK
c. Immune Manifestations: tender lymph nodes, recurrent sore throat, CHECK recurrent flu-like symptoms, CHECK general malaise, CHECK new sensitivities to food, CHECK medications CHECK and/or chemicals.
7. The illness persists for at least six months. CHECK It usually has a distinct onset,** CHECK although it may be gradual.
To be included, the symptoms must have begun or have been significantly altered after the onset of this illness. It is unlikely that a patient will suffer from all symptoms in criteria 5 and 6. The disturbances tend to form symptom clusters that may fluctuate and change over time. CHECK
*There is a small number of patients who have no pain or sleep dysfunction, but no other diagnosis fits except ME/CFS. A diagnosis of ME/CFS can be entertained when this group has an infectious illness type onset.
**Some patients have been unhealthy for other reasons prior to the onset of ME/CFS and lack detectable triggers at onset and/or have more gradual or insidious onset.

Exclusions: Exclude active disease processes that explain most of the major symptoms of fatigue, sleep disturbance, pain, and cognitive dysfunction. It is essential to exclude certain diseases, which would be tragic to miss: Addison’s disease, EXCLUDED Cushing’s Syndrome, EXCLUDED hypothyroidism, EXCLUDED hyperthyroidism, EXCLUDED iron deficiency, EXCLUDED other treatable forms of anemia, iron overload syndrome, diabetes mellitus, EXCLUDED and cancer. EXCLUDED It is also essential to exclude treatable sleep disorders such as upper airway resistance syndrome and obstructive or central sleep apnea; EXCLUDED rheumatological disorders such as rheumatoid arthritis, EXCLUDED lupus, EXCLUDED polymyositis ? and polymyalgia rheumatica; ? immune disorders such as AIDS; EXCLUDED neurological disorders such as multiple sclerosis (MS), ? Parkinsonism, ? myasthenia gravis ? and B12 deficiency; EXCLUDED infectious diseases such as tuberculosis, EXCLUDED chronic hepatitis, EXCLUDED Lyme disease, EXCLUDED etc.; primary psychiatric disorders EXCLUDED and substance abuse. EXCLUDED Exclusion of other diagnoses, which cannot be reasonably excluded by the patient’s history and physical examination, is achieved by laboratory testing and imaging. If a potentially confounding medical condition is under control, then the diagnosis of ME/CFS can be entertained if patients meet the criteria otherwise.

Co-Morbid Entities: Fibromyalgia Syndrome (FMS), CHECK Myofascial Pain Syndrome (MPS), Temporomandibular Joint Syndrome (TMJ), CHECK Irritable Bowel Syndrome (IBS), CHECK Interstitial Cystitis, Irritable Bladder Syndrome, Raynaud’s Phenomenon, CHECK Prolapsed Mitral Valve, Depression, CHECK Migraine, CHECK Allergies, CHECK Multiple Chemical Sensitivities (MCS), Hashimoto’s thyroiditis, CHECK Sicca Syndrome, etc. Such co-morbid entities may occur in the setting of ME/CFS. Others such as IBS may precede the development of ME/CFS by many years, but then become associated with it. The same holds true for migraines and depression. Their association is thus looser than between the symptoms within the syndrome. ME/CFS and FMS often closely connect and should be considered to be “overlap syndromes.”

Now, if that’s a fact, tell me: Am I lying?

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Appointments, tests, symptoms

I’m still dizzy. I’ve been dizzy for about 5 or 6 days now. Just unbalanced — things look odd, the world feels like it is slowly drifting to one side. This is different from the acute vertigo attack I had last year at the beginning of this illness and this is different than the “white-out” I’ve experienced my whole life when I stand up because I have low blood pressure. Last night, I woke up with stabbing pains in my stomach. I stayed awake for two hours, deep breathing. I don’t know if it was gas or what. I don’t care — I just want to track it. Other than that, my symptoms are: horrible headache, terrible back spams (mostly lower), my hands ache, neck pain, low-grade fever (99.7 when I took my temperature yesterday), and gritty eyes. But these are more like stone eyes or boulder eyes. Both eyes have what I used to call styes, but, upon deeper Internet exploration, may be something else… They’re not red or inflamed, they are small blisters on the inside lids. My top lip is swollen with some underground cystic acne nastiness. It looks like I was punched in the mouth. I look great, wish I could go out and socialize. But, seriously, I just miss feeling pretty. I miss getting dressed at all, let alone dressed UP. I miss not being in slippers.. a great pair of boots, a belt, jewelry … I miss brushing my hair and putting on mascara. I miss I miss I miss…

My thyroid hormone test results were fine. My liver and cholesterol panels looked fine. My bloodwork looked fine.

My first appointment of the week was acupuncture. He concentrated on harmonizing my shao yang symptoms which, according to Chinese medicine, are the alternating chills and fever I get daily.That night, after acupuncture, my daily headache became excruciating. It woke me up multiple times in the night. I thought it might have increased in severity from the acupuncture, which could have been true, but after the lingering brain cramps this morning, I actually think it might be from the Norco. I realise this is nuts seeing as I only took a quarter, but I can’t take Vicodin because of the headaches they give me and they’re the same ingredients.

I had my follow up with the Good Doctor on Tuesday. She said I seemed very tired and beat down. She thought it wasn’t a bad idea to take a holiday from the supplements if I felt overwhelmed and thought they might be contributing to the headache. But, she said I had to give my brain a holiday, too ~ stop worrying, planning, researching. Easier said than done. She didn’t want me to go off of the supplement and the birth control pill at the same time, which is fine because it’s not possible to go off the pill until I have a decent pain killer option. She had not received the results from the stool sample even though it’s been three weeks. She said once again, I never have these sort of troubles with labs! Stay tuned for the scathing essay I will write one day about medical mistakes. She said narcotics can absolutely give you a headache when you take them and give you a headache when they wear off. All in all, it was a pretty wasted trip. I think she took one look at my face and decided to concentrate on consoling me. Although, she did say she thought I should consider a brain MRI since my headaches are increasing in severity and waking me up at night. I think this disease is an autoimmune problem and/or a deep-seated pathogen that is causing neurological problems on top of all the others. I don’t think I have something that will show up on an MRI.

I also had a therapy appointment that day, too, and, since my chauffeur was also my spouse, I invited him into the session. It was good — for no other reason than they got to meet each other. I cried the whole time, explaining my guilt that he was doing so much and my grief that our lives had disappeared and my regret that we never did X/Y/Z before I got sick. Interestingly and to my relief, my therapist said that everything she has heard from me in the last few weeks is depressive thinking and is brand new. She said this whole year I have had anxiety over my sickness, leaving my career, what the future holds etc. — but that I had been a “trooper”. The depression of the last month is new and situational. I needed to hear that. It helps me say, get your shit together, girl, this isn’t you! When you are consumed by grief, it’s hard to remember what normal feels like. Even normal in sickness.

Today, I talked with an advocate for the M.E. Network with whom my aunt put me in touch (even my extended family has rallied to help me — I am very blessed). She is a nurse and had M.E. and recovered. She is adamantly against psychiatric drugs and she gave me her reasons. I agree with her and it was good to hear a healthcare worker not pushing the meds and talking about how compromised things have become because of pharmaceutical companies and their drug-pushing reps. However, getting a good pain killer and possibly an anti-anxiety or anti-depressant was my next course of action and now I feel hopeless again. Part of me just thought, if I give in and dope myself up, life would feel better even if it wasn’t better. She cautioned that M.E./C.F.S. patients’ brains are already compromised by the disease, so psychiatric drugs can make things much worse. I feel like I’m back to square one. Truly, my Rx is rest, short walks, baths, meditation and time…. while feeling like I’m dying for who knows how long? People have gone through worse. People are going through worse.

I’m grateful I’m not going through worse. This took me three days to write.

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Sick, month 11

E., that last post was for you. A tribute to our youth that has taken on a different meaning now.

I spent the weekend in bed for the most part. Today starts a fortnight of medical appointments every single week day. I’m worried about this. I should probably reschedule some, but they’re all ones I’ve been waiting for: overnight sleep study, neurologist, the Good Doctor follow up, a ten-week group therapy class that allows me to keep seeing my therapist for a little while longer for a much lower price tag, albeit in a group. Eek. I’m not a big public sharer, believe it or not, although maybe it’ll be okay because I am an open book, especially after this illness: I have never cared less what people think of what I say or how I look. That doesn’t mean I don’t care if I offend people or I don’t care if I smell, rather, I have no problem wearing no make-up, crying snottily, and talking about my bowel issues and crushing grief. Why disguise? What is there to hide?

Physically, I think I am worse than I’ve been since I left work. The pain is not as bad as it was in the days after my Big Day Out on the 13th, but, when the debilitating pain eases up, the regular pain, aches, exhaustion and flu-like symptoms are waiting underneath. As I mentioned before, I’ve only left the house 3 times in 11 days (for doc appointments). I haven’t gone to the grocery store, the drug store, the dog park ~ I haven’t done anything and I usually would be feeling a lot better by now. I feel faint, I am clammy, I keep getting a pitter-pattery heart and tight breathing, I am absolutely exhausted, I have a bad headache (this morning, there is an expanding and contracting ice pick in the back of my skull on the left), my muscles are stiff (I’m trying to come up with a better description ~ I walk and bend like the Tin Man, like I have immobile metal braces attached to all limbs), both hands and all fingers are in pain (haven’t had that in a while), and a new one: my leg muscles ACHE. They feel like they need to be moved and stretched, which is probably exactly what it is, but, it hurts. I lay in bed jiggling them, tensing them, punching them, trying to get the throb to ease up. And my brain is mush. I’m excited that I can type this morning because last night I could barely form sentences and not feeling smart is scary. Actually, the worst is not feeling quick anymore. The thing I valued most about my brain was how fast I could interpret, anticipate, respond, reason, argue, predict, accomplish… and I could tackle 10 things at a time. The ultimate multitasker. Gone.

Medicinally, I am taking a quarter of a Norco before bed, as well as my thyroid hormones, antihistamine nasal spray, albuterol inhaler, birth control pill and all the supplements and IBS-helping products. That’s it. I want to start something new this week ~ antibiotics or Lyrica or the Chinese herbs or something. I have an electric blanket on my bed, have changed to flannel sheets (heaven) and I’m trying a sun light box thing, which “is sure to deliver a therapeutic sense of well-being in any setting”, says the leaflet.

Emotionally, as I’ve said, I’m not in a great place. When you really start researching M.E., you realise that people don’t recover very often… hardly ever. So, I’m in this terrible shock-plan-grief cycle.

This can’t be happening. Okay, I’ll try X/Y/Z treatment. But, why? I’m just going to get X/Y/Z side effect.

I can’t believe I’m getting worse, not better. Okay, meditate, stay positive, have hope, keep going. But, there was so much I didn’t do, there was so much I didn’t try, there was so much I didn’t accomplish… Now, it’s all gone.

Wow, based on case studies, this can actually get much worse. Okay, I will concentrate on constant rest, every day. What’s the point? I’ll never have a life back, I’ll never have my health back, I’ll never have happiness.

My husband said, “You had the same problem riding a motorbike. You have to look where you want to go and lean into the curve with your eyes ahead of you. You have to focus on the point you want to get to.” I never looked at the end point; I was always afraid of the lean. I was always looking at where I was ~ scanning the ground for danger, watching my speed, making sure I hadn’t left my turn signal on ~ and not where I was going. Which is ironic since I know I am a future thinker and a constant planner.

For example, I have planned the documentary that I am going to make about M.E. I am going to travel this world and interview patients, doctors, people who have recovered, caregivers. It’s going to be informative and moving and it’s going to make some noise.

I have also planned the business I am going to start to bring services to home-bound patients. It’ll encompass everything: walk/wash/groom/play with your dog, wash your dishes, change your bed clothes and do your laundry, clean your home, mow your grass, cut your hair, take care of your feet, talk to you, listen to you, help with your meds, help you fill out paperwork, help you organise your files/calendar/appointments, bring a mobile library of movies, music and books from which you can borrow for free … I will have subcontractors that bring their services to your home. For example, landscapers, vets, acupuncturists, massage therapists, physical therapists, reiki practitioners, reflexologists, guided meditation helpers… It’s going to be epic and so fulfilling.

I have also planned to get a medical degree and go into research on M.E. Or, even better, doctor education. When I have some letters after my name, I will find a platform in the medical community and make some noise.

I have also planned to become a yoga teacher, a salsa dancer, a chef, a marathon runner, a gymnast, a horse rider, a dog trainer and, of course, a writer. Although, maybe, after years of this, I’ll be like Laura Hillenbrand and just not want to go there ~ Not want to write about M.E./C.F.S. because I live it.

Hope is hurting me, but only because I so desperately want to conquer the world. I am grateful for every minute of every day that my legs hold me up and my brain still works.

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From Today’s Daily Mail (UK) online

The comments after the article are very good, too…

http://poultonblog.dailymail.co.uk/2012/09/me-no-more-in-the-mind-than-multiple-sclerosis.html

ME is no more ‘in the mind’ than Multiple Sclerosis. When is the world going to get that?
Ever since I first wrote on the subject of Myalgic Encephalomyelitis – or to afford it a more user-friendly title, ME – earlier this year for MailOnline, http://www.dailymail.co.uk/debate/article-2141230/All-mind-Why-critics-wrong-deny-existence-chronic-fatigue.html I have been overwhelmed by the response from patients and their loved ones.

The over-riding message I have received has been one of gratitude. I can tell you that this is something of an unusual experience for a journalist writing for national newspapers.

These people have Facebook-ed and Tweeted me. I have received calls and e-mails. There have been forums addressing the article and pictures and cards received which outlined a sense of relief for millions of people.

Many of these voices – including some of the greatest scientific, legal and academic minds in the ME world – have echoed a collective sigh to see their illness validated in the media.

The very notion that the media, and the press in particular, can actually serve a positive purpose in society may come as a surprise. But sometimes it does. And my piece, according to the phenomenal response that greeted it, was just one of those times.

Here’s why. For decades, people who have suffered the debilitating – and sometimes fatal – condition of ME have been forced into a type of denial.

They have been told that their illness doesn’t really exist on the scale that they claim to experience it (due, in part, to it being labelled a ‘chronic fatigue syndrome’. A highly controversial description because it creates an image of something substantially less than what ME actually is).

They have been told, repeatedly, to ‘pull themselves together’ and to ‘G.E.T. A G.R.I.P.’ (a vile acronym actually used to describe the graded exercise prescribed, wrongly, to ME patients).

In short, it is not enough for people to have to endure serious multi-system issues that can leave them bed-bound for months at a time, but they are also made to feel bad for, well, feeling bad.

What an injustice.

From the insight I have gained into the ME world, I cannot overstate the consequences of such a twilight-type existence. One in which your body responds a specific way but you are told that it isn’t actually possible. That it’s not really happening. That you are imagining it.

And that myth, of it ‘being in the mind’ has been perpetuated worldwide.

Millions of sufferers have been left in the dark to deal with their illness. Sometimes, if they are fortunate, they will be supported by their loved ones – who are also in need of support, too – but often they are left to deal with it alone.

For those reasons, certainly, many ME patients may suffer depression but it is not the other way around – and it is deplorable to suggest it is.

It may surprise you to learn that I have detractors or, as modern parlance would have it, haters. These people troll me on the internet as if their lives depended on it.

Around about now they will be making comments like ‘get the violins out – here comes a sob story’. Well, ME is a sob story. And the way patients have been portrayed is grossly wrong and that injustice must be recognised as such.

In my experience, they are anything but cranks or victims but people who have simply waited too long to have the truth of their experience recognised.

And that, partly, arrived yesterday with the launch of the Lipkin Study, a significant multi-centre study into ME.

Chances are you may think otherwise for, as is common with any major ME announcements, there were a number of misleading reports prior to the press conference.

Subsequently, representatives from the ME society have announced their intention to pursue media outlets and seek rectification of some articles that have emerged.

In short, much of the media misunderstood the Lipkin study findings. Partly because some reports jumped-the-gun and took information from rumours and speculation rather than wait for the official announcement. But, it also occurred because the mis-information fed into already-established prejudices.

Many people, and for whatever reason, want to believe that ME is nothing more than feeling a little world-weary and tired.

It is nothing of the sort. It is a neurological condition that savages the body. People die from ME and millions across the world are being mistreated and misdiagnosed as a consequence of poor and hostile reporting.

Yesterday’s announcement – that ME was not a result of the XMRV virus – seemed to herald, to some, the idea that ME is not the result of any virus but is, infact, a psychological condition.

Wrong. Wrong. Oh, and for good measure, wrong again.

Many highly-respected and learned people have compared the overall devastation of ME to illnesses including Multiple Sclerosis and even AIDS – and with good reason.

Dr. Charles Shepherd of the ME Association responded to the misleading idea that ME cannot be contracted by any virus by saying:

“There is, in fact, a great deal of robust anecdotal and research evidence to demonstrate that a number of specific infections – examples include enteroviruses, dengue fever, glandular fever, hepatitis, parvovirus, Q fever, Ross River virus – trigger ME/CFS.”

Many ME sufferers like Dr. Shepherd have little doubt that their illness was triggered by one of these viruses. The problem has been getting it recognised and appropriately treated.

This is poor response, certainly, and even more so when you factor in that the World Health Organisation acknowledged it as a neurological condition over 30 years ago, then it becomes more than a little alarming.

But there have been powerful forces at play that have served to maintain the status quo on ME thinking, and they have proven more than a challenge to be reckoned with.

For the past 60 years, the illness has been hijacked by the psychiatric community as one of ‘theirs’. They have clutched ME to their collective bosom and have refused to release the iron-grasp on it.

This wholesale insistence of it being something that can be overcome with the right attitude has been highly detrimental to those who actually matter in this debate: the people who are suffering with it.

As a consequence, ME patients have been failed in terms of adequate treatment and significant funds are dove-tailed into Cognitive Behavioural Therapy and, even worse, Graded Exercise – which has been shown to have a detrimental impact on the health of ME patients.

The problems about treating a physical illness in a psychological manner are brilliantly explored in Angela Kennedy’s ‘Authors Of Our Own Misfortune?’ which tackles the topic with some considerable aplomb.

What we are dealing with here is a systematic neglect of ME patients – and we should be under no illusion about that.

Equally, we must be sure to tackle it – medically and in the media – without hysteria or bile.

One of the reasons that ME patients are so vocal is because the mis-information of their illness has resulted in a dangerous delay of appropriate research and treatment. If that were you, would you be quiet about it? I certainly would not!

So yes, ME is a modern-day scandal. The way it has been portrayed is shocking. The Lipkin study, despite its detractors, will enable a deeper exploration of the illness and how it impacts and ravages bodies and lives.

And, to the relief of ME sufferers worldwide, that understanding cannot come a moment too soon.

September 19, 2012 Comments (110) | 

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Just an update… not doing well.

Hey everyone,

I’ve taken a turn for the worse. I haven’t really recovered physically from my Big Day Out on the 13th. I’ve only left the house three times in the last week: therapy, acupuncture and the stress test appointment. Eight days without much improvement is unusual for me. That, in turn, has sent my mood into some deep, dark depths. That, in turn, is making my physical symptoms worse. My headache is constant, my back is in very bad pain, I sprained my neck in my sleep and it’s the worst it has been in months, my chest is tight, my concentration and cognitive abilities are shot. I kind of want to (jump, dance, laugh, sing, run) crawl into a hole and come out when they discover a cure for this disease.

I want to go off the birth control pill, but I’m afraid to. I want to take the Lyrica, but I’m afraid to. I want to take the Ambien, but I’m afraid to. I want to take the Chinese herbs, but I’m afraid to. I want to take an anti-depressant, but I’m afraid to. I want to try medicinal marijuana, but I’m afraid to. Yesterday, I wound up taking two quarters of a Norco for the pain, spaced out by about 8 hours and today I feel it ~ a sort of Norco hangover. I know it’s crazy, but my body is that sensitive and I am that sensitive to my body. I feel everything and I don’t want to help my pain, but cause edema or help my mood, but cause chest tightness… or whatever.

More than anything right now, I am mourning the loss of my husband’s old life. He has to do EVERYTHING and I’m not sure how he is holding it together. I am begging to talk about this and cry about this and be counselled about this all the time. He’s like, “What would you like for dinner?” And I say, “My fucking body back. A cure. My pain to go away. My fear to go away. My life to come back.” Only, I am currently unable to say it with a smile. So, I don’t say, “Pain-killers for an appetizer, a winning lotto ticket for the main course and a lobotomy for dessert, please, honey!” Instead, I look at him and start sobbing, “Why would I care about food? I just want to NOT BE SICK ANYMORE, don’t you get it?!”

One of my dearest, oldest friends is coming to see me today as she passes through town. She is vibrant and beautiful and I wish we could catch up without my sadness cloaked around me and my disease stepping on my shoulders. The day before yesterday, summer left. It’s now winter. Just like that. I am grateful for hot water bottles.