Hierarchical Clustering Applied to Chronic Pain Drawings Identifies Undiagnosed Fibromyalgia: Implications for Busy Clinical Practice.

Currently-used assessments for fibromyalgia require clinicians to suspect a fibromyalgia diagnosis, a process susceptible to unintentional bias. Automated assessments of standard patient-reported outcomes (PROs) could be used to prompt formal assessments, potentially reducing bias. We sought to determine whether hierarchical clustering of patient-reported pain distribution on digital body map drawings predicted fibromyalgia diagnosis. Using an observational cohort from the University of Pittsburgh's Patient Outcomes Repository for Treatment registry, which contains PROs and electronic medical record data from 21,423 patients (March 17, 2016-June 25, 2019) presenting to pain management clinics, we tested the hypothesis that hierarchical clustering subgroup was associated with fibromyalgia diagnosis, as determined by ICD-10 code. Logistic regression revealed a significant relationship between the body map cluster subgroup and fibromyalgia diagnosis. The cluster subgroup with the most body areas selected was the most likely to receive a diagnosis of fibromyalgia when controlling for age, gender, anxiety, and depression. Despite this, more than two-thirds of patients in this cluster lacked a clinical fibromyalgia diagnosis. In an exploratory analysis to better understand this apparent underdiagnosis, we developed and applied proxies of fibromyalgia diagnostic criteria. We found that proxy diagnoses were more common than ICD-10 diagnoses, which may be due to less frequent clinical fibromyalgia diagnosis in men. Overall, we find evidence of fibromyalgia underdiagnosis, likely due to gender bias. Coupling PROs that take seconds to complete, such as a digital pain body map, with machine learning is a promising strategy to reduce bias in fibromyalgia diagnosis and improve patient outcomes. PERSPECTIVE: This investigation applies hierarchical clustering to patient-reported, digital pain body maps, finding an association between body map responses and clinical fibromyalgia diagnosis. Rapid, computer-assisted interpretation of pain body maps would be clinically useful in prompting more detailed assessments for fibromyalgia, potentially reducing gender bias.

Identifying Predictors of Recommendations for and Participation in Multimodal Nonpharmacological Treatments for Chronic Pain Using Patient-Reported Outcomes and Electronic Medical Records.

OBJECTIVE: High-quality chronic pain care emphasizes multimodal treatments that include medication and nonpharmacological treatments. But it is not clear which patients will participate in nonpharmacological treatments, such as physical therapy or mental health care, and previous research has shown conflicting evidence. METHODS: We used the Patient Outcomes Repository for Treatment (PORT) registry, which combines patient-reported outcomes data with electronic medical records. In this retrospective observational study, we performed two separate multinomial regression analyses with feature selection to identify PORT variables that were predictive of 1) recommendation of a nonpharmacological treatment by the provider and 2) patient participation in nonpharmacological treatments. Two hundred thirty-six patients were recommended (REC) or not recommended (NO REC) a nonpharmacological treatment, and all REC patients were classified as participating (YES) or not participating (NO) in the recommendations. RESULTS: Female gender and a diagnosis of Z79 "Opioid drug therapy" were significant positive and negative predictors of nonpharmacological treatment recommendations, respectively. Schedule II opioid use at initial presentation and recommendations for rehabilitation therapy were significant predictors of nonparticipation. CONCLUSIONS: Patients using opioids are less likely to be recommended nonpharmacological treatments as part of multimodal chronic pain care and are less likely to participate in nonpharmacological treatments once recommended. Males are also less likely to be recommended nonpharmacological treatments. Patients referred for rehabilitation therapies are less likely to comply with those recommendations. We have identified patients in vulnerable subgroups who may require additional resources and/or encouragement to comply with multimodal chronic pain treatment recommendations.

Significant predictors of poor quality of life in older asthmatics.

BACKGROUND: Morbidity and mortality from asthma are high in older adults and quality of life (QOL) might be lower, although standardized measurements of QOL have not been validated in this population. OBJECTIVE: To determine predictors of asthma-related QOL in older adults. METHODS: Allergy and pulmonary outpatients (n = 164) at least 65 years old with an objective diagnosis of asthma completed the Mini-Asthma Quality of Life Questionnaire (mAQLQ). Demographics, medical history, and mean value for daily elemental carbon attributable to traffic, a surrogate for diesel exposure, were obtained. Regression analysis was used to determine predictors of mAQLQ scores. RESULTS: Total mAQLQ (mean ± SD 5.4 ± 1.1) and symptom, emotional, and activity domain scores were similar to those of younger populations, whereas environmental domain scores (4.4 ± 1.7) appeared lower. Poorer mAQLQ scores were significantly associated with emergency department visits (adjusted ß [aß] = -1.3, where ß values indicate the strength and direction of association, P < .0001) and with poorer scores on the Asthma Control Questionnaire (aß = -0.7, P < .0001). Greater ECAT exposure (aß = -1.6, P < .02), female sex (aß = -0.4, P < .006), body mass index of at least 30 kg/m(2) (aß = -0.4, P < .01), gastroesophageal reflux (aß = -0.4, P < .01), nonatopic status (aß = -0.5, P < .002), and asthma onset before 40 years of age (aß = -0.5, P < .004) were significantly associated with poorer mAQLQ scores. CONCLUSION: The mAQLQ scores in older adults with stable asthma were similar to those in younger populations and were predictive of other measurements of asthma control, verifying that the mAQLQ is an appropriate tool in older adults with asthma. Traffic pollution exposure was the strongest predictor of poorer asthma-related QOL in older adults with asthma.

Case study investigating effect of implementing strategies for reducing patient complaints in an outpatient pain clinic.

This case study explores the impact of improving communication for reducing complaints in an outpatient pain clinic. A retrospective review was conducted for two 6-month periods prior to and for 6 months after implementing a structured communication strategy that included changes in staff behavior and documentation. Most complaints were related to not receiving opioids as part of the treatment plan. In the first treatment period prior to implementation, 6 of 3,653 patients lodged complaints. In the second period prior to implementation, 8 of 3,992 patients lodged complaints. Following implementation, 3 of 3,879 patients lodged complaints. Using structured communication strategies appeared to reduce complaints and facilitate chart documentation when addressing difficult patient situations including opioid issues.

Criteria for the diagnosis of fibromyalgia: validation of the modified 2010 preliminary American College of Rheumatology criteria and the development of alternative criteria.

OBJECTIVE: To validate the 2011 modification of the 2010 American College of Rheumatology (ACR) preliminary criteria for the diagnosis of fibromyalgia (2011ModCr) and develop alternative criteria in a sample of patients with diverse pain disorders that are commonly seen in everyday practice by pain specialists, rheumatologists, and psychologists. METHODS: Eight clinicians from geographically varied locations in the US evaluated patients with chronic pain and psychiatric disorders using a standard set of questions that included the 2011ModCr questions, the Symptom Impact Questionnaire (SIQR), a 28-area pain location inventory (PLI), and the Short Form 36. Alternative diagnostic criteria were developed from the same data set using logistic regression and receiver operating curve analysis. RESULTS: Complete data on 321 patients were evaluated; there were 135 patients with fibromyalgia (according to the 1990 ACR criteria) and 186 patients with 16 other common chronic pain problems. Comparing the 2011ModCr with the 1990 ACR criteria provided a sensitivity of 83%, a specificity of 67%, and a correct classification of 74%. Alternative criteria were derived from the 10-item symptom score from the SIQR symptoms and the 28-area PLI. Maximal diagnostic accuracy was obtained with ≥17 pain sites (range 0-28) and an SIQR symptom score of ≥21 (range 0-50). These alternative criteria had a diagnostic sensitivity of 81%, a specificity of 80%, and a correct classification of 80%. CONCLUSION: The 2011ModCr had robust operating characteristics. Alternative criteria based on symptom items from the SIQR and pain locations from the PLI had comparable operating characteristics, with somewhat better specificity and ease of use.

Including a range of outcome targets offers a broader view of fibromyalgia treatment outcome: results from a retrospective review of multidisciplinary treatment.

BACKGROUND: Fibromyalgia is associated with substantial functional disability. Current drug and non-drug treatments result in statistically significant but numerically small improvements in typical numeric measures of pain severity and fibromyalgia impact. OBJECTIVE: The aim of the present study was to evaluate additional measures of pain severity and functional outcome that might be affected by fibromyalgia treatment. METHODS: This retrospective review evaluated outcomes from 274 adults with fibromyalgia who participated in a six-week, multidisciplinary treatment programme. Pain and function were evaluated on the first and final treatment visit. Pain was evaluated using an 11-point numerical scale to determine clinically meaningful pain reduction (decrease ≥ 2 points) and from a pain drawing. Function was evaluated by measuring active range of motion (ROM), walking distance and speed, upper extremity exercise repetitions, and self-reports of daily activities. RESULTS: Numerical rating scores for pain decreased by 10-13% (p < 0.01) and Fibromyalgia Impact Questionnaire (FIQ) scores decreased by 20% (p < 0.001). More substantial improvements were noted when using alternative measures. Clinically meaningful pain relief was achieved by 37% of patients, and the body area affected by pain decreased by 31%. ROM showed significant improvements in straight leg raise and cervical motion, without improvements in lumbar ROM. Daily walking distance increased fourfold and arm exercise repetitions doubled. CONCLUSION: Despite modest albeit statistically significant improvements in standard measures of pain severity and the FIQ, more substantial pain improvement was noted when utilizing alternative measures of pain and functional improvement. Alternative symptom assessment measures might be important outcome measures to include in drug and non-drug studies to better understand fibromyalgia treatment effectiveness.

Chronic traffic pollution exposure is associated with eosinophilic, but not neutrophilic inflammation in older adult asthmatics.

OBJECTIVE: Airway inflammatory patterns in older asthmatics are poorly understood despite high asthma-related morbidity and mortality. In this study, we sought to define the relationship between exposure to traffic pollutants, biomarkers in induced sputum, and asthma control in older adults. METHODS: Induced sputum was collected from 35 non-smoking adults ≥65 years with a physician's diagnosis of asthma and reversibility with a bronchodilator or a positive methacholine challenge. Patients completed the Asthma Control Questionnaire (ACQ), and Elemental Carbon Attributable to Traffic (ECAT), a surrogate for chronic diesel particulate exposure, was determined. Equal numbers of subjects with high (≥0.39 µg/m(3)) versus low (<0.39 µg/m(3)) ECAT were included. Differential cell counts were performed on induced sputum, and myeloperoxidase (MPO) and eosinophil peroxidase (EPO) were measured in supernatants. Regression analyses were used to evaluate the relationship between sputum findings, ACQ scores, and ECAT. RESULTS: After adjustment for potential confounders, subjects with poorly controlled asthma based on ACQ ≥ 1.5 (n = 7) had significantly higher sputum eosinophils (median = 4.4%) than those with ACQ < 1.5 (n = 28; eosinophils = 2.6%; ß = 10.1 [95% CI = 0.1-21.0]; p = 0.05). Subjects with ACQ ≥ 1.5 also had significantly higher sputum neutrophils (84.2% versus 65.2%; ß = 7.1 [0.2-14.6]; p = 0.05). Poorly controlled asthma was associated with higher sputum EPO (ß = 2.4 [0.2-4.5], p = 0.04), but not MPO (p = 0.9). High ECAT was associated with higher eosinophils (ß = 10.1 [1.8-18.4], p = 0.02) but not higher neutrophils (p = 0.6). CONCLUSIONS: Poorly controlled asthma in older adults is associated with eosinophilic and neutrophilic inflammation. Chronic residential traffic pollution exposure may be associated with eosinophilic, but not neutrophilic inflammation in older asthmatics.

Brief, self-report fibromyalgia screener evaluated in a sample of chronic pain patients.

OBJECTIVE: To validate a self-report fibromyalgia screener in a chronic pain population. DESIGN: Adults with chronic pain were evaluated with a six-item, self-report fibromyalgia screening tool based on revised American College of Rheumatology (ACR) fibromyalgia diagnostic criteria, with fibromyalgia diagnosed when patients experienced chronic pain and scored ≥13 on the ACR fibromyalgia symptom severity scale. Patients were independently assigned clinical diagnoses by treating clinicians. SETTING: University-based, tertiary care pain clinic. SUBJECTS: Three hundred thirty-seven mixed chronic pain patients. RESULTS: Agreement between the clinical diagnosis and screener diagnosis was good (P < 0.001), with 76% sensitivity and 82% specificity. CONCLUSION: A self-administered, brief fibromyalgia screening questionnaire can effectively identify chronic pain patients who will likely have clinical fibromyalgia.

Milnacipran for fibromyalgia: a useful addition to the treatment armamentarium.

INTRODUCTION: Antidepressants are used to treat a variety of chronic pain conditions including peripheral neuropathy, headache, and more recently, fibromyalgia. The antidepressant milnacipran blocks the reuptake of norepinephrine and serotonin and is used for the management of fibromyalgia. AREAS COVERED: The article contains data primarily obtained from the MEDLINE database using a PubMed search of the keywords including milnacipran, fibromyalgia and depression. Of the available serotonin norepinephrine reuptake inhibitors, milnacipran has greater potency in inhibiting reuptake of norepinephrine relative to serotonin and is proposed to work by attenuating pain signals. Milnacipran is well tolerated and effective for fibromyalgia pain when given in divided doses of 100 - 200 mg daily. Studies show that milnacipran may be effective for fibromyalgia-associated symptoms including depression and fatigue. EXPERT OPINION: Milnacipran provides modest fibromyalgia pain relief and is best used as part of a multidisciplinary treatment approach. While milnacipran was not studied in fibromyalgia patients with major depression, it may be a wise choice for fibromyalgia patients with depressive symptoms and patients for whom sedation, dizziness, edema or weight gain with gabapentin and pregabalin is a problem. Milnacipran has been found to be beneficial for treating some troublesome fibromyalgia-associated symptoms, including fatigue and cognitive dysfunction.

Impact of animal-assisted therapy for outpatients with fibromyalgia.

OBJECTIVES: Animal-assisted therapy using dogs trained to be calm and provide comfort to strangers has been used as a complementary therapy for a range of medical conditions. This study was designed to evaluate the effects of brief therapy dog visits for fibromyalgia patients attending a tertiary outpatient pain management facility compared with time spent in a waiting room. DESIGN: Open label with waiting room control. SETTING: Tertiary care, university-based, outpatient pain management clinic. SUBJECTS: A convenience sample of fibromyalgia patients was obtained through advertisements posted in the clinic. INTERVENTIONS: Participants were able to spend clinic waiting time with a certified therapy dog instead of waiting in the outpatient waiting area. When the therapy dog was not available, individuals remained in the waiting area. OUTCOME MEASURES.: Self-reported pain, fatigue, and emotional distress were recorded using 11-point numeric rating scales before and after the therapy dog visit or waiting room time. RESULTS: Data were evaluated from 106 therapy dog visits and 49 waiting room controls, with no significant between-group demographic differences in participants. Average intervention duration was 12 minutes for the therapy dog visit and 17 minutes for the waiting room control. Significant improvements were reported for pain, mood, and other measures of distress among patients after the therapy dog visit, but not the waiting room control. Clinically meaningful pain relief (≥2 points pain severity reduction) occurred in 34% after the therapy dog visit and 4% in the waiting room control. Outcome was not affected by the presence of comorbid anxiety or depression. CONCLUSIONS: Brief therapy dog visits may provide a valuable complementary therapy for fibromyalgia outpatients.

Poor asthma control and exposure to traffic pollutants and obesity in older adults.

BACKGROUND: Environmental and host predictors of asthma control in older asthmatic patients (>65 years old) are poorly understood. OBJECTIVE: To examine the effects of residential exposure to traffic exhaust and other environmental and host predictors on asthma control in older adults. METHODS: One hundred four asthmatic patients 65 years of age or older from allergy and pulmonary clinics in greater Cincinnati, Ohio, completed the validated Asthma Control Questionnaire (ACQ), pulmonary function testing, and skin prick testing to 10 common aeroallergens. Patients had a physician's diagnosis of asthma, had significant reversibility in forced expiratory volume in 1 second or a positive methacholine challenge test result, and did not have chronic obstructive pulmonary disease. The mean daily residential exposure to elemental carbon attributable to traffic (ECAT) was estimated using a land-use regression model. Regression models were used to evaluate associations among independent variables, ACQ scores, and the number of asthma exacerbations, defined as acute worsening of asthma symptoms requiring prednisone use, in the past year. RESULTS: In the adjusted model, mean daily residential exposure to ECAT greater than 0.39 µg/m(3) was significantly associated with poorer asthma control based on ACQ scores (adjusted ß = 2.85; 95% confidence interval [CI], 0.58-5.12; P = .02). High ECAT levels were also significantly associated with increased risk of asthma exacerbations (adjusted odds ratio, 3.24; 95% CI, 1.01-10.37; P = .05). A significant association was found between higher body mass index and worse ACQ scores (adjusted ß = 1.15; 95% CI, 0.53-1.76; P < .001). Atopic patients (skin prick test positive) had significantly better ACQ scores than nonatopic patients (adjusted ß = -0.39; 95% CI, -0.67 to -0.11; P < .01). CONCLUSION: Higher mean daily residential exposure to traffic exhaust, obesity, and nonatopic status are associated with poorer asthma control among older asthmatic patients.

Genetic variation in small proline rich protein 2B as a predictor for asthma among children with eczema.

BACKGROUND: Small proline rich protein 2B (SPRR2B) is a skin and lung epithelial protein associated with allergic inflammation in mice that has not been evaluated in human atopic diseases. OBJECTIVE: To determine whether single-nucleotide polymorphisms (SNPs) in SPRR2B are associated with childhood eczema and with the phenotype of childhood eczema combined with asthma. METHODS: Genotyping for SPRR2B and filaggrin (FLG) was performed in 2 independent populations: the Cincinnati Childhood Allergy & Air Pollution Study (CCAAPS; N = 762; birth-age, 4 years) and the Greater Cincinnati Pediatric Clinical Repository (GCPCR; N = 1152; ages 5-10 years). Eczema and eczema plus asthma were clinical outcomes based on parental report and clinician's diagnosis. Genetic analyses were restricted to whites and adjusted for sex in both cohorts and adjusted for environmental covariates in CCAAPS. RESULTS: Variants in SPRR2B were not significantly associated with eczema in either cohort after Bonferroni adjustment. Children from both cohorts with the CC genotype of the SPRR2B rs6693927 SNP were at 4 times the risk for eczema plus asthma (adjusted odds ratio, 4.1; 95% confidence interval, 1.5-10.9; P = .005 in CCAAPS; and adjusted odds ratio, 4.0; 95% confidence interval, 1.8-9.1; P < .001 in the GCPCR), however. SNPs in SPRR2B were not in strong linkage disequilibrium with the R501X and del2282 FLG mutations, and these findings were independent of FLG. CONCLUSIONS: An SNP in SPRR2B was predictive of asthma among white children with eczema from 2 independent populations. SPRR2B polymorphisms may serve as important predictive markers for the combined eczema plus asthma phenotype.

Animal-assisted therapy at an outpatient pain management clinic.

OBJECTIVE: The objective of this study was to evaluate the effects of brief therapy dog visits to an outpatient pain management facility compared with time spent in a waiting room. DESIGN: The design of this study is open-label. Setting. This study was conducted in a university tertiary care adult chronic pain outpatient clinic. SUBJECTS: The subjects of this study include outpatients, adults accompanying outpatients to their appointments, and clinic staff. Intervention. Participants were able to spend clinic waiting time with a certified therapy dog instead of waiting in the outpatient waiting area. When the therapy dog was not available, individuals remained in the waiting area. OUTCOME MEASURES: Self-reported pain, fatigue, and emotional distress were recorded using 11-point numeric rating scales before and after the therapy dog visit or waiting room time. RESULTS: Two hundred ninety-five therapy dog visits (235 with patients, 34 family/friends, and 26 staff) and 96 waiting room surveys (83 from patients, 6 family/friends, and 7 staff) were completed over a 2-month study period. Significant improvements were reported for pain, mood, and other measures of distress among patients after the therapy dog visit but not the waiting room control, with clinically meaningful pain relief (decrease ≥2 points) in 23% after the therapy dog visit and 4% in the waiting room control. Significant improvements were likewise seen after therapy dog visits for family/friends and staff. CONCLUSIONS: Therapy dog visits in an outpatient setting can provide significant reduction in pain and emotional distress for chronic pain patients. Therapy dog visits can also significantly improve emotional distress and feelings of well-being in family and friends accompanying patients to appointments and clinic staff.

Perimenstrual eletriptan prevents menstrual migraine: an open-label study.

OBJECTIVE: To prospectively evaluate the efficacy of perimenstrual prophylaxis with eletriptan to reduce headaches in women identified with menstrual migraine (MM). METHODS: Female migraineurs self-reporting a substantial relationship between migraine and menses were evaluated with 3 consecutive months of daily headache recording diaries. A relationship between menses and migraine was evaluated using International Classification of Headache Disorders (ICHD-II) criteria and a probability model called Probability MM. Women prospectively diagnosed with ICHD-II MM were treated for 3 consecutive months with perimenstrual eletriptan 20 mg 3 times daily starting 2 days prior to the expected onset of menstruation and continued for a total of 6 days. Headache activity was compared during the 3 months of recording prior to eletriptan therapy and 3 months with eletriptan perimenstrual prevention therapy. RESULTS: Three months of pretreatment prospective diaries were completed by 126 women. ICHD-II menstrually related migraine was diagnosed in 74%, with pure MM in 7%. Among those women diagnosed with ICHD-II MM, 61 completed at least 1 treatment month. Overall change in headache activity was a 46% decrease. The mean percentage of treated menses without migraine occurring during the 6 days of treatment was 71%. The percentage of subjects with 1, 2, and 3 migraine-free menstrual periods (no migraines occurring 2 days before menses through the first 3 days of menstruation) with eletriptan, respectively, were 14%, 19%, and 53%. Among those subjects who remained headache-free during the 6 days of eletriptan treatment, migraine occurred during the 3 days immediately after discontinuing eletriptan for 9%. Perimenstrual eletriptan was generally tolerated and no abnormalities were identified on the 6(th) day of treatment using either blood pressure recording or electrocardiogram. CONCLUSIONS: Among patients with prospectively identified MM, eletriptan 20 mg 3 times daily effectively reduced MM. A significant reduction in headache activity occurred for 53% of patients.

A prospective comparison between ICHD-II and probability menstrual migraine diagnostic criteria.

OBJECTIVE: To prospectively evaluate the diagnosis of menstrual migraine (MM) by comparing 2 diagnostic systems. METHODS: Female migraineurs self-reporting a substantial relationship between migraine and menses were evaluated with 3 consecutive months of daily headache recording diaries. A relationship between menses and migraine was evaluated using International Classification of Headache Disorders (ICHD-II) criteria and a probability model called Probability MM. RESULTS: Three months of pretreatment prospective diaries were completed by 126 women. ICHD-II menstrually related migraine was diagnosed in 73.8% with pure MM in 7.1%. ICHD-II and Probability diagnoses agreed for all cases of ICHD-II non-MM and pure MM, with disagreement among women diagnosed with ICHD-II menstrually related migraine, only half of whom were identified as having a relationship with menses greater than chance alone using the Probability model. Interestingly, 20% of those women self-reporting a substantial relationship between migraine and menses were not prospectively diagnosed with MM using either diagnostic system. Differences in menstrual vs nonmenstrual headaches were greater when using the Probability model. CONCLUSIONS: Prospective headache diaries are needed to diagnose MM. A probability-based method, which considers the chance occurrence of headaches during the menstrual cycle, identifies fewer women as having menstrually related migraine compared with the diary-based methods recommended by the current ICHD-II candidate criteria.

Fibromyalgia and headache: an epidemiological study supporting migraine as part of the fibromyalgia syndrome.

Fibromyalgia is defined by widespread body pain, tenderness to palpation of tender point areas, and constitutional symptoms. The literature reports headache in about half of fibromyalgia patients. The current epidemiological study was designed to determine the prevalence and characteristics of headache in fibromyalgia patients. Treatment-seeking fibromyalgia patients were evaluated with measures for fibromyalgia, chronic headache, quality of life, and psychological distress. Multivariate analysis of variance (MANOVA) and t-tests were used to identify significant differences, as appropriate. A total of 100 fibromyalgia patients were screened (24 fibromyalgia without headache and 76 fibromyalgia with headache). International Headache Society diagnoses included: migraine alone (n = 15 with aura, n = 17 without aura), tension-type alone (n = 18), combined migraine and tension-type (n = 16), post-traumatic (n = 4), and probable analgesic overuse headache (n = 6). Fibromyalgia tender point scores and counts and most measures of pain severity, sleep disruption, or psychological distress were not significantly different between fibromyalgia patients with and without headache. As expected, the fibromyalgia patients with headache scored higher on the Headache Impact Test (HIT-6) (62.1 +/- 0.9 vs 48.3 +/- 1.6, p < 0.001). HIT-6 scores were >60 in 80% of fibromyalgia plus headache patients, representing severe impact from headache, and 56-58 in 4%, representing substantial impact. In summary, chronic headache was endorsed by 76% of treatment-seeking fibromyalgia patients, with 84% reporting substantial or severe impact from their headaches. Migraine was diagnosed in 63% of fibromyalgia plus headache patients, with probable analgesic overuse headache in only 8%. General measures of pain, pain-related disability, sleep quality, and psychological distress were similar in fibromyalgia patients with and without headache. Therefore, fibromyalgia patients with headache do not appear to represent a significantly different subgroup compared to fibromyalgia patients without headache. The high prevalence and significant impact associated with chronic headache in fibromyalgia patients, however, warrants inclusion of a headache assessment as part of the routine evaluation of fibromyalgia patients.

In vivo sensitization to purified Hevea brasiliensis proteins in health care workers sensitized to natural rubber latex.

BACKGROUND: Thirteen proteins of natural rubber latex (Hevea brasiliensis) known to bind human IgE have been isolated and characterized as Hev b allergens. However, the in vivo importance of native Hev b allergens has not been defined in health care workers (HCWs) with natural rubber latex (NRL) allergy. OBJECTIVES: The principal aim of this study was to identify the major in vivo Hev b allergens in HCWs with NRL allergy confirmed by percutaneous sensitivity to nonammoniated latex (NAL). METHODS: Skin prick testing was performed with 7 (native) proteins purified from NAL (Hev b 1, 2, 3, 4, 6.01, 7.01, and a newly described Hev b 13) and recombinant Hev b 5 in 62 HCWs with histories of NRL allergy (group 1) confirmed by percutaneous reactivity to NAL and in 49 atopic HCWs without NRL allergy (group 2). Serial 10-fold concentrations of Hev b proteins (5 x 10(-5) microg/mL to 50 microg/mL) were tested; serum samples of subjects were assayed for serum specific IgE by immunoassays. RESULTS: Hev b 2, Hev b 5, Hev b 6.01, and Hev b 13 produced skin reactions in more than 60% of group 1 subjects, with Hev b 1, 3, 4, and 7.01 eliciting reactions in less than 50%. Only 1 of 49 group 2 workers reacted to a single Hev b antigen (Hev b 13). Specificity of 7 Hev b allergens was 100% and 98% for Hev b 13 in identifying workers with confirmed NRL allergy. Specific IgE by AlaSTAT and CAP immunoassays was elevated in 40 of 60 (67%) and 33 of 62 (53%) of NAL-reactive workers and produced false-positive test results in 4 of 49 (8%) and 3 of 48 (6%) group 2 subjects, respectively. CONCLUSION: Hev b 2, 5, and 6.01 are major in vivo allergens and Hev b 13 is a new major in vivo allergen among HCWs with allergy to NRL.

Clinical and occupational outcomes in health care workers with natural rubber latex allergy.

BACKGROUND: There is limited information pertaining to clinical outcomes and economic consequences of natural rubber latex (NRL) allergy in health care workers (HCWs). OBJECTIVE: To evaluate retrospectively health and economic outcomes in HCWs identified with NRL allergy and percutaneous reactivity to NRL. METHODS: Sixty-seven HCWs with NRL allergy, confirmed by percutaneous reactivity to non-ammoniated latex (NAL) extract, were administered a detailed questionnaire to evaluate clinical and economic outcomes of active work and environmental interventions subsequent to recognition of work-related symptoms associated with NRL gloves. RESULTS: Diagnoses based on predetermined case definitions associated with direct or indirect exposure to NRL gloves included contact urticaria in 67 (100%); work-related rhinitis in 23; work-related asthma symptoms in 25; and work-related anaphylaxis in 4 workers. Work related symptoms reportedly resolved in 44 of 49 (90%) of NAL skin test-positive workers who had reported skin, respiratory, and/or systematic symptoms and remained in their current work area and who switched to non-NRL gloves. Four of 24 (17%) workers with work-related asthma symptoms were compelled to change employment to NRL-safe workplaces, resulting in a mean 24% reduction in annual income. CONCLUSIONS: Clinical outcomes in this group of HCWs with NRL allergy were favorable after institution of interventions but incurred deleterious consequences in a minority of workers.