Fibromyalgia diagnostic model derived from combination of American College of Rheumatology 1990 and 2011 criteria / 대한통증학회지

BACKGROUND: We aimed to explore the American College of Rheumatology (ACR) 1990 and 2011 fibromyalgia (FM) classification criteria’s items and the components of Fibromyalgia Impact Questionnaire (FIQ) to identify features best discriminating FM features. Finally, we developed a combined FM diagnostic (C-FM) model using the FM’s key features. METHODS: The means and frequency on tender points (TPs), ACR 2011 components and FIQ items were calculated in the FM and non-FM (osteoarthritis [OA] and non-OA) patients. Then, two-step multiple logistic regression analysis was performed to order these variables according to their maximal statistical contribution in predicting group membership. Partial correlations assessed their unique contribution, and two-group discriminant analysis provided a classification table. Using receiver operator characteristic analyses, we determined the sensitivity and specificity of the final model. RESULTS: A total of 172 patients with FM, 75 with OA and 21 with periarthritis or regional pain syndromes were enrolled. Two steps multiple logistic regression analysis identified 8 key features of FM which accounted for 64.8% of variance associated with FM group membership: lateral epicondyle TP with variance percentages (36.9%), neck pain (14.5%), fatigue (4.7%), insomnia (3%), upper back pain (2.2%), shoulder pain (1.5%), gluteal TP (1.2%), and FIQ fatigue (0.9%). The C-FM model demonstrated a 91.4% correct classification rate, 91.9% for sensitivity and 91.7% for specificity. CONCLUSIONS: The C-FM model can accurately detect FM patients among other pain disorders. Re-inclusion of TPs along with saving of FM main symptoms in the C-FM model is a unique feature of this model.

Challenges in fibromyalgia diagnosis: from meaning of symptoms to fibromyalgia labeling

Fibromyalgia (FM) is a contested illness with ill-defined boundaries. There is no clearly defined cut-point that separates FM from non-FM. Diagnosis of FM has been faced with several challenges that occur, including patients' health care-seeking behavior, symptoms recognition, and FM labeling by physicians. This review focuses on important but less visible factors that have a profound influence on under- or over-diagnosis of FM. FM shows different phenotypes and disease expression in patients and even in one patient over time. Psychosocial and cultural factors seem to be a contemporary ferment in FM which play a major role in physician diagnosis even more than having severe symptom levels in FM patients. Although the FM criteria are the only current methods which can be used for classification of FM patients in surveys, research, and clinical settings, there are several key pieces missing in the fibromyalgia diagnostic puzzle, such as invalidation, psychosocial factors, and heterogeneous disease expression. Regarding the complex nature of FM, as well as the arbitrary and illusory constructs of the existing FM criteria, FM diagnosis frequently fails to provide a clinical diagnosis fit to reality. A physicians' judgment, obtained in real communicative environments with patients, beyond the existing constructional scores, seems the only reliable way for more valid diagnoses. It plays a pivotal role in the meaning and conceptualization of symptoms and psychosocial factors, making diagnoses and labeling of FM. It is better to see FM as a whole, not as a medical specialty or constructional scores.

Serum Vitamin D Status in Iranian Fibromyalgia Patients: according to the Symptom Severity and Illness Invalidation

BACKGROUND: This study was designed to assess serum vitamin D status (25-OHD) in the fibromyalgia (FM) patients and to compare it with a healthy control group. It also aimed to investigate the correlation of serum vitamin D level with FM symptom severity and invalidation experiences. METHODS: A total of 74 consecutive patients with FM and 68 healthy control participants were enrolled. The eligible FM patients completed the Illness Invalidation Inventory (3*I), the Revised Fibromyalgia Impact Questionnaire (FIQR) and a short-form health survey (SF-12). Venous blood samples were drawn from all participants to evaluate serum 25-OHD levels. Mann-Whitney tests and multiple logistic regression analyses were performed and Spearman's correlations were calculated. RESULTS: 88.4% of FM patients had low levels of serum 25-OHD. FM patients had significantly higher level of serum 25-OHD than the control group (17.24 ± 13.50 and 9.91 ± 6.47 respectively, P = 0.0001). There were no significant correlations between serum 25-OHD levels and the clinical measures of disease impact, invalidation dimensions, and health status. Multiple logistic regression analyses revealed that an increased discounting of the disease by the patient's spouse was associated with a 4-fold increased risk for vitamin D deficiency (OR = 4.36; 95% CI, 0.95-19.87, P = 0.05). CONCLUSIONS: This study showed that although high rates of vitamin D insufficiency or deficiency were seen among FM patients and healthy non-FM participants, but it seems there was no intrinsic association between FM and vitamin D deficiency. Addressing of invalidation experience especially by the patient's spouse is important in management of FM.

The acute effect of maximal exercise on plasma beta-endorphin levels in fibromyalgia patients

BACKGROUND: This study aimed to investigate the effect of strenuous exercise on β-endorphine (β-END) level in fibromyalgia (FM) patients compared to healthy subjects. METHODS: We enrolled 30 FM patients and 15 healthy individuals. All study participants underwent a treadmill exercise test using modified Bruce protocol (M.Bruce). The goal of the test was achieving at least 70% of the predicted maximal heart rate (HRMax). The serum levels of β-END were measured before and after the exercise program. Measurements were done while heart rate was at least 70% of its predicted maximum. RESULTS: The mean ± the standard deviation (SD) of exercise duration in the FM and control groups were 24.26 ± 5.29 and 29.06 ± 3.26 minutes, respectively, indicating a shorter time to achieve the goal heart rate in FM patients (P < 0.003). Most FM patients attained 70% HRMax at lower stages (stage 2 and 3) of M.Bruce compared to the control group (70% versus 6.6%, respectively; P < 0.0001). Compared to healthy subjects, FM patients had lower serum β-END levels both in baseline and post-exercise status (Mean ± SD: 122.07 ± 28.56 µg/ml and 246.55 ± 29.57 µg/ml in the control group versus 90.12 ± 20.91 µg/ml and 179.80 ± 28.57 µg/ml in FM patients, respectively; P < 0.001). CONCLUSIONS: We found that FM patients had lower levels of β-END in both basal and post-exercise status. Exercise increased serum the β-END level in both groups but the average increase in β-END in FM patients was significantly lower than in the control group.

The acute effect of maximal exercise on plasma beta-endorphin levels in fibromyalgia patients

BACKGROUND: This study aimed to investigate the effect of strenuous exercise on β-endorphine (β-END) level in fibromyalgia (FM) patients compared to healthy subjects. METHODS: We enrolled 30 FM patients and 15 healthy individuals. All study participants underwent a treadmill exercise test using modified Bruce protocol (M.Bruce). The goal of the test was achieving at least 70% of the predicted maximal heart rate (HRMax). The serum levels of β-END were measured before and after the exercise program. Measurements were done while heart rate was at least 70% of its predicted maximum. RESULTS: The mean ± the standard deviation (SD) of exercise duration in the FM and control groups were 24.26 ± 5.29 and 29.06 ± 3.26 minutes, respectively, indicating a shorter time to achieve the goal heart rate in FM patients (P < 0.003). Most FM patients attained 70% HRMax at lower stages (stage 2 and 3) of M.Bruce compared to the control group (70% versus 6.6%, respectively; P < 0.0001). Compared to healthy subjects, FM patients had lower serum β-END levels both in baseline and post-exercise status (Mean ± SD: 122.07 ± 28.56 µg/ml and 246.55 ± 29.57 µg/ml in the control group versus 90.12 ± 20.91 µg/ml and 179.80 ± 28.57 µg/ml in FM patients, respectively; P < 0.001). CONCLUSIONS: We found that FM patients had lower levels of β-END in both basal and post-exercise status. Exercise increased serum the β-END level in both groups but the average increase in β-END in FM patients was significantly lower than in the control group.

value of serum NR2 antibody in prediction of post-cardiopulmonary resuscitation survival

N-methyl-D-aspartate receptor subunits antibody [NR2-ab] is a sensitive marker of ischemic brain damage in clinical circumstances, such as cerebrovascular accidents. We aimed to assess the value of serum NR2-ab in predicting the post-cardiopulmonary resuscitation [CPR] survival. In this cohort study, we examined serum NR2-ab levels 1 hour after the return of spontaneous circulation [ROSC] in 49 successfully resuscitated patients. Patients with traumatic or asphyxic arrests, prior neurological insults, or major medical illnesses were excluded. Participants were followed until death or hospital discharge. Demographic data, coronary artery disease risk factors, time before initiation of CPR, and CPR duration were documented. In addition, Glasgow coma scale [GCS], blood pressure, and survival status of patients were recorded at 1, 6, 24, and 72 hour[s] after ROSC. Descriptive analyses were performed, and the Cox proportional hazard model was applied to assess if NR2-ab level is an independent predictive factor of survival. 49 successfully resuscitated patients were evaluated; 27 [55%] survived to hospital discharge, 4 [8.1%] were in vegetative state, 10 [20.4%] were physically disabled, and 13 [26.5%] were physically functional. Within 72 hours of ROSC all of the 12 NR2-ab positive patients died. In contrast, 31 [84%] of the NR2-ab negative patients survived. Sensitivity, specificity, positive and negative likelihood ratios of NR2-ab in prediction of survival were 54.5% [95%CI=32.7%-74.9%], 100% [95%CI=84.5%-100%], infinite, and 45.5% [95%CI=28.8%-71.8%], respectively. Subsequent analysis showed that both NR2-ab status and GCS were independent risk factors of death. A positive NR2-ab serum test 1 hour after ROSC correlated with lower 72-hour survival. Further studies are required to validate this finding and demonstrate the value of a quantitative NR2-ab assay and its optimal time of measurement

The Iceberg Nature of Fibromyalgia Burden: The Clinical and Economic Aspects

This review has focused on important but less visible aspects of fibromyalgia (FM) with respect to the high impact of this disorder on patients and societies. FM is a common but challengeable illness. It is characterized by chronic widespread pain, which can be accompanied by other symptoms including fatigue, sleep disturbances, cognitive dysfunction, anxiety and depressive episodes. While our understanding of this debilitating disorder is limited, diagnosis and treatment of this condition is very difficult, even in the hands of experts. Due to the nature of disease, where patients experience invalidation by medical services, their families and societies regarding the recognition and management of disease, direct, indirect and immeasurable costs are considerable. These clinical and economic costs are comparable with other common diseases, such as diabetes, hypertension and osteoarthritis, but the latter usually receives much more attention from healthcare and non-healthcare resources. Present alarming data shows the grave and "iceberg-like" burden of FM despite the benign appearance of this disorder and highlights the urgent need both for greater awareness of the disease among medical services and societies, as well as for more research focused on easily used diagnostic methods and target specific treatment.

Serum cortisol levels as a predictor of neurologic survival in successfully resuscitated victims of cardiopulmonary arrest

Out-of-hospital cardiac arrest [OHCA] is the most stressful lifetime event for the victims and an important issue for the emergency physicians. The status of the hypothalamic pituitary- adrenal axis [HPA] function in successfully resuscitated victims of Cardiopulmonary arrest has been recently of an interest for the researchers. In a prospective cohort study, 50 successfully resuscitated OHCA victims' serum cortisol levels were measured 5 minutes and 1 hour after return of spontaneous circulation [ROSC]. The data were analyzed comparing the one-week neurologic survival. Fifty blood samples were obtained for serum cortisol levels after 5 minutes of ROSC. Fourteen patients [28%] pronounced death during one hour after CPR. Blood sample from living 36 patients after one hour post-CPR were obtained for second cortisol assay. Eleven patients [22%] were neurologically survived after one week. Seven patients [14%] were discharged finally from hospital with good neurologic recovery. The serum cortisol levels in both the neurologically surviving and the non-surviving after 5 minutes of ROSC patients were 63.4 +/- 13.6 and 43.2 +/- 25.5[microg/ml], [mean +/- S.D., respectively] and after 1 hour of ROSC patients' serum cortisol levels were 64.9 +/- 13.1 and 47.3 +/- 27.1[microg/ml], [mean +/- S.D., respectively]. The difference was significantly higher in neurologically survived group in both 5 minutes and 1 hour after ROSC [P= 0.015 and 0.013 respectively]. serum cortisol levels after 5 minutes and one hour of ROSC in victims of Cardiopulmonary arrest are significantly higher in neurologically survived than non-survived patients