New Zealand researcher Dr. L.O. Simpson has theorized that Chronic Fatigue Syndrome results from "insufficient oxygen availability due to impaired capillary blood flow." Simpson attributes the impaired capillary blood flow to smaller-than-usual capillaries and to the presence of abnormal red blood cells.

Vasoconstriction

When the core body temperature is cooled below approximately 37 degrees Celsius (98.6 F), special mechanisms are set into play to conserve the heat that is already in the body, and still other mechanisms are set into play to increase the rate of heat production.

One of the first effects is intense vasoconstriction of the skin vessels over the entire body. The posterior hypothalamus strongly activates the sympathetic nervous signals to the skin blood vessels, and intense vasoconstriction occurs throughout the body. This vasoconstriction obviously prevents the conduction of heat from the internal portions of the body to the skin. Consequently, with maximal vasoconstriction the only heat that can leave the body is that which can be conducted directly through the insulater layers of the skin. This effect conserves the quantity of heat in the body. ("Human Physiology and Mechanisms of Disease", Guyton, pg.554)

Sympathetic impulses are transmitted to the adrenal medullae at the same time that they are transmitted to all the blood vessels. These impulses cause the medullae to secrete both epinephrine and norepinephrine into the circulating blood. These two hormones are carried in the blood stream to all parts of the body, where they act directly on the blood vessels, usually to cause vasoconstriction. (ibid, pg.166)

Norepinephrine has vasoconstrictor effects in almost all vascular beds of the body, and epinephrine has similar effects in most, but not all, beds. (ibid, pg.167)

According to the findings of one study, Norepinephrine-evoked pain in fibromyalgia (FM). The adrenal hormone norepinephrine may be responsible for the body pain associated with FM. The studies conclusion: Fibromyalgia patients have norepinephrine-evoked pain. This finding supports the hypothesis that fibromyalgia may be a sympathetically maintained pain syndrome.

Another study, Abnormal microcirculation and temperature in skin above tender points in patients with fibromyalgia, showed that vasoconstriction occurs in the skin above tender points in FM patients, supporting the hypothesis that FM is related to local hypoxia in the skin above tender points.

This makes sense; The norepinephrine which causes vasoconstriction is likely responsible for the pain that is associated with the tender points in FM.

Exercise

Some studies have found that with exercise, the person with CFS/FM actually experiences a drop in body temperature. The opposite response one would expect to happen.

"In coming years it was discovered that little was guaranteed to exacerbate chronic fatigue syndrome more rapidly or more profoundly than exercise, particularly rigorous exercise. During aerobic exercise, CFS victims were found to experience a sudden drop in body temperature and a decrease in oxygen flow to the brain - the opposite of what occurs in normal people. The oxygen deficit in the brain persisted for several days after even brief activity" - Ismael Mena, "Study of Cerebral Perfusion by NeuroSPECT in Patients with Chronic Fatigue Syndrome,"

In a healthy person, exercise increases blood flow and oxygen delivery to the cells. The cells generate ATP, much of which is expended to generate heat in the body. With the increase in body temperature comes a further increase in metabolism, energy production, and more heat. The metabolic rate increases by 15 percent for each degree celsius increase in body temperature.

In the case of a person with CFS/FM, exercise causes an increase in blood flow to the extremities. However, due to blockages that impair energy production in the mitochondria, less ATP is generated. The ATP that is generated is used to fuel the activity of the exercise, relatively little is available for the generation of heat. A lot of the ATP generated is via the anaerobic process of glycolysis. Accumulations of a byproduct of glycolysis, pyruvic acid, causes the tissue to become more acidic, indirectly blocking energy production in the mitochondria.

because the blood is being pumped out to the extremities and the tissue is not generating much heat, the net effect is that the blood is being cooled down, thus lowering the body temperature. This would explain the findings in the study of the effects of exercise and CFS.

It can probably be deduced that massage may also have a similar affect, to lower the core body temperature. One goal of massage is to increase blood circulation in the tissue. This is contrary to one goal of vasoconstriction in the tissue, which is to conserve heat in the body. Increasing blood flow in the tissue by massage will warm up the tissue. But at what cost? Lowering the core body temperature? And, how will the body respond? The adrenals may likely secrete more norepinephrine to constrict blood flow to conserve heat. With the increased norepinephrine may also come an increase in pain.

In a Nutshell

Due to blockages in mitochondrial energy production of ATP, the body is unable to maintain the desired operating temperature of 98.6 degrees F. To conserve heat, blood flow to the extremities is decreased via vasoconstriction, signaled by the hormone norepinephrine. Elevated levels of blood norepinephrine contribute to body pain. Exercise has an effect of further lowering body temperature in people with CFS/FM. More norepinephrine is secreted in an attempt to conserve heat, and consequently more pain results.

Tips and Tricks

Exercise is good. But take care not overdo it. Dress warm to minimize heat loss. If the outside air temperature is cold, or even cool, in addition to warm clothing wear a warm hat and gloves. Most of the heat lost from the body escapes through the head.

Walking is probably one of the better exercises that you can do. If you are not able to do this, then do stretching exercises, slowly increasing the amount of exercise that you can tolerate.

If you have a FIR sauna, then finish your exercise session with a little time in the sauna and drink a couple glasses of water. This will help to move some of the acidic metabolic waste out of your body.

If getting a massage, find a therapist that will first warm your body prior to giving the massage. There are some massage therapists now using FIR saunas. Warm up before the massage and then after the massage use the FIR heat again. Drink a large glass of water, before and after to help the body expel metabolic waste products.

Canada Day, formerly known as Dominion Day, is Canada's national day. It is a federal statutory holiday, celebrating the anniversary of the July 1, 1867 enactment of the British North America Act of 1867, which united Canada as a single country of four provinces. Canada Day observances take place throughout Canada as well as internationally.

Frequently referred to as "Canada's birthday," particularly in the popular press, the occasion marks the joining of the British colonies of Nova Scotia, New Brunswick, and the Province of Canada into a federation of four provinces (the Province of Canada being divided, in the process, into Ontario and Quebec) on July 1, 1867.

However, though Canada is regarded as having become a kingdom in its own right on that date, the British Parliament at first kept limited rights of political control over the new country, which were shed by stages over the years until the last vestiges were ended in 1982, when the Constitution Act patriated the Canadian constitution. Canada Day thus differs from Independence Day celebrations in other countries in that it does not commemorate a clear-cut date of complete independence.

In April we did an article on Medications Used to Treat Fibromyalgia. We thought it might be helpful for you to learn more about these medications. This month we will take an in-depth look at Cymbalta.

Cymbalta has been approved by the FDA for the management of Fibromyalgia (FM) and has been demonstrated to help reduce pain and improve function. Cymbalta is available only by prescription.

When Cymbalta was studied in patients with FM, many people felt significant pain reduction, compared with patients taking placebo. Individual results may vary. Learn about how Cymbalta is believed to work.

Cymbalta Is Simple to Take

Cymbalta comes in a capsule and can be taken once a day to help lessen pain associated with FM. Cymbalta can be taken with or without food. You should not break, open, or chew the capsule. It should be swallowed whole. Make sure you take only the dose your doctor prescribes.

Cymbalta is not for everyone. As with all medications, certain side effects may be experienced.

In clinical studies of FM, the most commonly reported side effect of Cymbalta was mild to moderate nausea. Read more below about the most common side effects and potential risks associated with treatment.

Discuss With Your Doctor

Do not use Cymbalta together with:

• thioridazine (Mellaril®)
• isocarboxazid (Marplan®)
• tranylcypromine (Parnate®)
• phenelzine (Nardil®)
• rasagiline (Azilect®)
• selegiline (Eldepryl®, Emsam®)

Serious and sometimes fatal reactions can occur when these medicines are taken with Cymbalta. You must wait at least 14 days after stopping an MAO inhibitor before you can take Cymbalta. After you stop taking Cymbalta, you must wait at least 14 days before you start taking an MAOI. You must wait 5 days after stopping Cymbalta before you can take an MAOI.

Do not use this medication if you are allergic to Cymbalta, or if you have untreated or uncontrolled glaucoma.

Before taking Cymbalta, tell your doctor if you are allergic to any drugs, or if you have:

• Liver or Kidney Disease
• Seizures or Epilepsy
• Bipolar Disorder (manic depression)
• History of Drug Abuse or Suicidal Thoughts

If you have any of these conditions, you may not be able to use Cymbalta, or you may need a dosage adjustment or special tests during treatment.

You may have an increased risk of suicidal thoughts or behavior at the start of treatment with an antidepressant medication, especially if you are under 18 years old. Talk with your doctor about this risk. While you are taking Cymbalta you will need to be monitored for worsening symptoms of depression and/ or suicidal thoughts during the first weeks of treatment, or whenever your dose is changed.

In addition to you watching for changes in your own symptoms, your family or other caregivers should be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Cymbalta may be harmful to an unborn baby, and may cause problems in a newborn baby if the mother takes the medication late in pregnancy (during the third trimester). Tell your doctor if you are pregnant or plan to become pregnant during treatment. Cymbalta can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.

Older adults may be more sensitive to the side effects of this medication. Do not give this medication to anyone under 18 years old without the advice of a doctor.

What To Avoid

Avoid drinking alcohol while taking Cymbalta. Alcohol may increase the risk of damage to your liver. Avoid using other medicines that make you sleepy such as:

• Cold Medicine
• Pain Medication
• Muscle Relaxers
• Medicine for Seizures
• Medication for Depression or Anxiety

Cymbalta can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

Side Effects

Get emergency medical help if you have any of these signs of an allergic reaction:

• skin rash or hives
• difficulty breathing
• swelling of your face, lips, tongue, or throat

Contact your doctor promptly if you have any of the following side effects, especially if they are new symptoms or if they get worse:

• Mood Changes
• Anxiety
• Panic Attacks
• Trouble Sleeping
• Irritability
• Agitation
• Aggressiveness
• Severe Restlessness
• Mania (mental and/ or physical hyperactivity)
• Thoughts of Suicide or Hurting Yourself

Call your doctor at once if you have any of these SERIOUS side effects:

• Nausea
• Stomach Pain
• Low fever
• Loss of Appetite
• Dark Urine, Clay-Colored Stools
• Jaundice (yellowing of the skin or eyes)
• Restlessness
• Overactive reflexes
• Hallucinations
• Loss of Coordination
• Fainting
• Coma
• Nausea
• Vomiting
• Diarrhea
• Fever
• Fast Heartbeat

Other less serious side effects are more likely to occur, such as:

• Constipation
• Drowsiness, Dizziness
• Headache
• Sleep Problems (insomnia)
• Weight Changes
• Feeling Anxious or Nervous
• Increased Sweating
• Sore Throat
• Decreased Sex Drive, Impotence, or Difficulty Having An Orgasm

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

Drug Interactions

Talk to your doctor before taking any medicine for pain, arthritis, fever, or swelling. This includes:

• Aspirin
• Ibuprofen (Advil®, Motrin®)
• Naproxen (Aleve®, Naprosyn®)
• Diclofenac (Voltaren®)
• Indomethacin
• Piroxicam (Feldene®)
• Nabumetone (Relafen®)
• Etodolac (Lodine®), and others

Taking any of these drugs with Cymbalta may cause you to bruise or bleed easily. Before taking Cymbalta, tell your doctor if you are using any of the following medicines:

• cimetidine (Tagamet®)
• linezolid (Zyvox®)
• lithium (Lithobid®, Eskalith®)
• St. John's wort
• tramadol (Ultram®)
• tryptophan (sometimes called L-tryptophan®)
• warfarin (Coumadin®)
• almotriptan (Axert®)
• frovatriptan (Frova®)
• sumatriptan (Imitrex®)
• naratriptan (Amerge®)
• rizatriptan (Maxalt®)
• zolmitriptan (Zomig®)
• amitriptyline (Elavil®)
• amoxapine (Ascendin®)
• clomipramine (Anafranil®)
• desipramine (Norpramin®)
• escitalopram (Lexapro®)
• fluoxetine (Prozac®, Sarafem®)
• fluvoxamine (Luvox®)
• imipramine (Janimine®, Tofranil®)
• nortriptyline (Pamelor®)
• paroxetine (Paxil®)
• protriptyline (Vivactil®)
• sertraline (Zoloft®)
• trimipramine (Surmontil®)
• venlafaxine (Effexor®)

If you are using any of these drugs, you may not be able to use Cymbalta, or you may need dosage adjustments or special tests during treatment.

There may be other drugs not listed that can affect Cymbalta. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. We hope this article has been helpful. Next month our focus will be on Elavil®.

Independence Day (commonly known as the Fourth of July) is a federal holiday commemorating America's independence from the Kingdom of Great Britain on July 4, 1776. Americans celebrate Independence Day with fireworks, parades, barbecues and picnics.

Though the Fourth of July is iconic to Americans, some claim the date itself is somewhat arbitrary. New Englanders had been fighting Britain since April 1775. The first motion in the Continental Congress for independence was made on June 4, 1776. After hard debate, the Congress voted unanimously, but secretly, for independence from Great Britain on July 2 and appointed Thomas Jefferson to write a draft. The Congress reworked the draft until a little after eleven o'clock, July 4, when twelve colonies voted for adoption (New York abstained from both votes) and released a copy to the printers signed only by John Hancock, President of the Congress, and Secretary Charles Thomson.

Abstract

Fibromyalgia (FM) has been associated with alterations in brain morphometry and abnormal dopaminergic neurotransmission. Evidence from preclinical models has demonstrated that dopamine plays a role in promoting neuronal integrity. We therefore sought to confirm previous findings of reduced gray matter density in subjects with FM and to determine whether variations in dopamine metabolism might affect gray matter density.

Voxel-based morphometry was used to evaluate anatomical magnetic resonance imaging data from 30 female FM subjects in comparison with 20 age- and gender-matched healthy control subjects. In addition, data from a subset of subjects from both groups who had previously participated in our positron emission tomography study using radiolabeled DOPA (n = 14; 6 FM subjects and 8 control subjects) was used to determine whether correlation might exist between gray matter density and dopamine metabolism.

We found a significant reduction in gray matter density within the bilateral parahippocampal gyri, right posterior cingulate cortex, and left anterior cingulate cortex. In addition, a positive correlation was demonstrated between an index of dopamine metabolism from the ventral tegmental area wherein cell bodies of corticolimbic projection neurons originate and gray matter density, specifically in the bilateral parahippocampal gyri and left pregenual cortex.

The current results confirm our previous findings that FM is associated with altered brain morphometry. Alterations in dopamine metabolism might contribute to the associated changes in gray matter density.

Perspective

Fibromyalgia is associated with reductions in gray matter density within brain regions ostensibly involved in phenomena related to the disorder, including enhanced pain perception, cognitive dysfunction, and abnormal stress reactivity. Given mounting evidence of abnormal dopaminergic neurotransmission associated with the disorder, the strong correlation between dopamine metabolism and gray matter density provides insight as to the pathophysiology that might contribute to these changes.

Getting a pedicure is a popular way to pamper and groom the feet. But watch out. You could walk away with an infection due to the use of unsanitary tools and contaminated footbaths if the pedicure salon doesn't practice proper hygiene.

According to the American Academy of Dermatology, pedicure health risks include fungal infections, such as athlete's foot and nail fungus, and bacterial skin infections, including MRSA (Methicillin-resistant Staphylococcus aureus), a potentially serious antibiotic-resistant staph infection.

That doesn't mean you shouldn't indulge in a pedicure. But you should take a few steps, before baring your toes, to ensure foot safety.

Before You Go

For starters, schedule your pedicure first thing in the morning. Pedicure instruments and footbaths are typically cleanest at the beginning of the day, according to the American Podiatric Medical Association (APMA).

Ask the person you make your appointment with how much time there is between appointments. Pedicure disinfectants require at least 10 minutes to work. "If the salon is putting one client after another into the foot bowl, that's a red flag that your feet may be vulnerable to an infection," says Elizabeth Kurtz, DPM, a podiatrist in Chicago and APMA spokesperson.

Other Tips Before You Go:

• Don't shave your legs. The Centers for Disease Control and Prevention and Environmental Protection Agency warn against shaving, using hair removal creams, or waxing your legs and feet during the 24 hours before getting a pedicure. "Hair removal can cause cuts or subtle abrasions that you don't even notice on your feet," says Dr. Kurtz. These tiny openings in the skin can allow bacteria and fungus to enter.


• Bring your own pedicure tools. Bacteria and fungus can easily move from one person to the next on pedicure utensils that haven't been properly sterilized. "Bringing your own tools will eliminate that risk," says Kurtz. Some tools, like nail buffers and emery boards, can't be sterilized. Even in the most pristine salons, these tools may not be replaced after each customer.

Before You Remove Your Shoes

Once you're inside, take a look around. Do the surfaces and water where clients put their feet appear sanitary? If they look dirty, find another place to get a pedicure. Also, check out the bathroom. If the bathrooms are dirty, that's a clue that the pedicure salon may not have high hygiene standards.

Don't be afraid to ask about the salon's disinfecting procedures. Footbaths should be drained and washed with disinfectant between customers and every night, and pedicure instruments should be soaked in disinfectant between customers. Footbaths and instruments that aren't properly disinfected could harbor bacteria and fungus that can cause infections to the feet. You could also ask about these points when you make your appointment, but your eyes can help determine the truth.

While You Are There

• Don't let the pedicure technician cut your cuticles. "When this protective barrier gets cut or removed, it's easy for bacteria and fungus to enter," says Kurtz. Pushing back the cuticle can also damage it, increasing the risk of infection to your feet.


• Be sure your feet are smoothed properly. A standard pedicure usually includes removal of dead skin on the feet, but this should be done with a pumice stone or foot file, not a razor-type tool. If used incorrectly, a razor can easily remove too much skin and cause infection or permanent damage to the skin.

After You Leave

Be on guard for infections to your feet in the days and weeks following a pedicure. The appearance of a pimple or boil that's red, swollen, or painful could be a sign of a bacterial staph infection. An itchy foot rash or yellowish toenail could signal a fungal infection. Visit a podiatrist or primary care physician if you suspect you have an infection.

Taking these precautions will help ensure that getting a pedicure will leave your feet both pretty and healthy. Says Kurtz: "Most pedicures are perfectly safe, but it pays to be proactive to protect your feet."

BACKGROUND: NICE guidelines suggest that patients with Chronic Fatigue Syndrome/Myalgic Encephalitis (CFS/ME) should be managed in Primary Care. Practice Nurses are increasingly being involved in the management of long-term conditions, so are likely to also have a growing role in managing CFS/ME. However their attitudes to, and experiences of patients with CFS/ME and its management must be explored to understand what barriers may exist in developing their role for this group of patients. The aim of this study was to explore Practice Nurses' understanding and beliefs about CFS/ME and its management.

METHODS: Semi-structured interviews with 29 Practice Nurses. Interviews were transcribed verbatim and an iterative approach used to develop themes from the dataset.

RESULTS: Practice nurses had limited understanding about CFS/ME which had been largely gained through contact with patients, friends, personal experiences and the media rather than formal training. They had difficulty seeing CFS/ME as a long term condition. They did identify a potential role they could have in management of CFS/ME but devalued their own skills in psychological intervention, and suggested counselling would be an appropriate therapeutic option. They recognised a need for further training and on going supervision from both medical and psychological colleagues. Some viewed the condition as contentious and held pejorative views about CFS/ME. Such scepticism and negative attitudes will be a significant barrier to the management of patients with CFS/ME in primary care.

CONCLUSION: The current role of Practice Nurses in the ongoing management of patients with CFS/ME is limited. Practice Nurses have little understanding of the evidence-base for treatment of CFS/ME, particularly psychological therapies, describing management options in terms of advice giving, self-help or counselling. Practice Nurses largely welcomed the potential development of their role in this area, but identified barriers and training needs which must be addressed to enable them to feel confident managing of patients with this condition. Training must begin by addressing negative attitudes to patients with CFS/ME.

Over the years, many have viewed Fibromyalgia syndrome (FM) as a so-called "functional disorder" and patients have experienced a concomitant lack of interest and legitimacy from the medical profession.

The symptoms have not been explained by peripheral mechanisms alone nor by specific central nervous system mechanisms. In this study, we objectively evaluated the cerebral response to individually calibrated pain provocations of a pain-free body region (thumbnail).

The study comprised 16 female FM patients and 16 individually age-matched controls. Brain activity was measured using functional magnetic resonance imaging (fMRI) during individually calibrated painful pressures representing 50mm on a visual analogue scale (VAS) ranging from 0 to 100mm.

Patients exhibited higher sensitivity to pain provocation than controls as they required less pressure to evoke equal pain magnitudes (UA=48, p .002). Despite lower pressures applied in patients at VAS 50mm, the fMRI-analysis revealed no difference in activity in brain regions relating to attention and affect or regions with sensory projections from the stimulated body area.

However, in the primary link in the descending pain regulating system (the rostral anterior cingulate cortex) the patients failed to respond to pain provocation. The attenuated response to pain in this brain region is the first demonstration of a specific brain region where the impairment of pain inhibition in FM patients is expressed.

These results validate previous reports of dysfunctional endogenous pain inhibition in FM and advance the understanding of the central pathophysiologic mechanisms, providing a new direction for the development of successful treatments in FM.

Chronic fatigue syndrome (CFS) is a specific clinical condition that characterises unexplained disabling fatigue and a combination of non-specific accompanying symptoms for at least 6 months, in the absence of a medical diagnosis that would otherwise explain the clinical presentation.

Other common symptoms include headaches, myalgia, arthralgia, and post-exertional malaise; cognitive difficulties, with impaired memory and concentration; unrefreshing sleep; and mood changes. Similar disorders have been described for at least two centuries and have been differently named neurasthenia, post-viral fatigue, myalgic encephalomyelitis and chronic mononucleosis.

Recent longitudinal studies suggest that some people affected by chronic fatigue syndrome improve with time but that most remain functionally impaired for several years. The estimated worldwide prevalence of CFS is 0.4–1% and it affects over 800,000 people in the United States and approximately 240,000 patients in the UK. No physical examination signs are specific to CFS and no diagnostic tests identify this syndrome. The pathophysiological mechanism of CFS is unclear. The main hypotheses include altered central nervous system functioning resulting from an abnormal immune response against a common antigen; a neuroendocrine disturbance; cognitive impairment caused by response to infection or other stimuli in sentient people.

The current concept is that CFS pathogenesis is a multifactorial condition. Various studies have sought evidence for a disturbance in immunity in people with CFS. An alteration in cytokine profile, a decreased function of natural killer (NK) cells, a presence of autoantibodies and a reduced responses of T cells to mitogens and other specific antigens have been reported. The observed high level of pro-inflammatory cytokines may explain some of the manifestations such as fatigue and flu-like symptoms and influence NK activity.

Abnormal activation of the T lymphocyte subsets and a decrease in antibody-dependent cell-mediated cytotoxicity have been described. An increased number of CD8+ cytotoxic T lymphocytes and CD38 and HLA-DR activation markers have been reported, and a decrease in CD11b expression associated with an increased expression of CD28+ T subsets has been observed. This review discusses the immunological aspects of CFS and offers an immunological hypothesis for the disease processes.

Fred and his wife Edna went to the state fair every year. Every year Fred would say, "Edna, I'd like to ride in that there airplane."

And every year Edna would say, "I know Fred, but that airplane ride costs ten dollars, and ten dollars is ten dollars."

One year Fred and Edna went to the fair and Fred said, "Edna, I'm 71 years old. If I don't ride that airplane this year I may never get another chance."

Edna replied, "Fred that there airplane ride costs ten dollars, and ten dollars is ten dollars."

The pilot overheard them and said, "Folks, I'll make you a deal. I'll take you both up for a ride. If you can stay quiet for the entire ride and not say one word, I won't charge you, but if you say one word it's ten dollars."

Fred and Edna agreed and up they go. The pilot does all kinds of twists and turns, rolls and dives, but not a word is heard. He does all his tricks over again, but still not a word.

They land and the pilot turns to Fred, "By golly, I did everything I could think of to get you to yell out, but you didn't."

Fred replied, "Well, I was going to say something when Edna fell out of the plane, but ten dollars is ten dollars."

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