Elevated DAS28-ESR in patients with rheumatoid arthritis who have comorbid fibromyalgia is associated more with tender joint counts than with patient global assessment or swollen joint counts: implications for assessment of inflammatory activity.

OBJECTIVES: More than 20% of rheumatoid arthritis (RA) patients have comorbid fibromyalgia (FM+), which may elevate DAS28-ESR (disease activity score 28-erythrocyte sedimentation rate) and other indices, resulting in challenges to assess inflammatory disease activity. Although several reports indicate that elevated patient global assessment (PATGL) may elevate DAS28 in the absence of inflammatory activity, less information is available concerning the other three components, tender joint count (TJC), swollen joint count (SJC), and erythrocyte sedimentation rate (ESR), to possibly elevate DAS28 in FM+ vs. FM- RA patients. METHODS: A PubMed search identified 14 reports which presented comparisons of DAS28-ESR and its four components in RA FM+ vs. FM- groups. Median DAS28, component arithmetic differences, pooled effect sizes and 95% confidence intervals were analysed in the FM+ vs. FM- groups. RESULTS: In FM+ vs. FM- groups, median DAS28 was 5.3 vs. 4.2, SJC 4.0 vs. 3.0, TJC 13.2 vs. 5.3, PATGL 61.6 vs. 39.9, ESR 26.3 vs. 26.5. DAS28-ESR was classified as "high" (>5.1) in 11/14 FM+ groups and "moderate" (3.2-5.1) in all 14 FM- groups. Effect sizes in FM+ vs. FM- groups for DAS28-ESR, SJC, TJC, PATGL, and ESR were large (≥0.8) in 10/14, 1/13, 12/13, 7/13, and 1/13 comparisons, respectively, and pooled effect sizes 0.84 (0.3, 1.4), 0.33 (-0.4, 1.0), 1.27 (0.01, 2.5), 0.91 (-0.6, 2.4), and 0.07 (-0.6, 0.7), respectively. CONCLUSIONS: DAS28-ESR is elevated significantly in FM+ vs. FM- RA patients; pooled effect sizes were highest for TJC, followed by PATGL, SJC and ESR. The findings appear relevant to response and remission criteria, treat-to-target, and general management of RA.

Health inequities and societal costs for patients with fibromyalgia and their spouses: a Danish cohort study.

OBJECTIVE: To assess the burden of illness of people with fibromyalgia (FM) and their spouses compared with selected match populations in Denmark. METHODS: Population-based, cohort case-control study using data from Danish registries from 1994 to 2021. Individuals with an FM diagnosis were identified from the National Patient Register (2008-2019) and randomly matched to a 1:4 general population comparator. Spouses or persons co-living with subjects with FM at the time of diagnosis were compared with matched comparator spouses. Healthcare and societal costs, socioeconomic status and occurrence of comorbidities were evaluated for subjects with FM, spouses and controls. RESULTS: 9712 subjects with FM (94.9% females, mean age 50 years) and 5946 spouses were included. At year of diagnosis, subjects with FM had significantly more comorbidities compared with controls, including significantly more comorbid rheumatic disorders. The highest risk at the time of FM diagnosis was a comorbid diagnosis of ankylosing spondylitis (OR 7.0, 95% CI 4.9 to 10.0). Significantly more comorbidities were also observed in spouses. Subjects with FM and spouses had higher healthcare and public transfer costs and lower income from employment at all timepoints. Loss of income from employment in subjects with FM occurred years before establishment of the FM diagnosis. The employment rate after diagnosis was 22%. 10 years after the FM diagnosis, 50% received disability pension as compared with 11% of matched controls. The observed net average increased societal cost for subjects with FM amounted to €27 193 per patient-year after diagnosis. CONCLUSION: FM has major health and socioeconomic consequences for patients, their partners and society and call for improved healthcare strategies matching patients' needs.

Trends in the treatment of fibromyalgia in South Korea between 2011 and 2018: a retrospective analysis of cross-sectional health insurance data.

OBJECTIVES: Fibromyalgia treatment trends vary globally; however, the trend in South Korea has not been investigated yet. This study aimed to analyse the fibromyalgia treatment trends in South Korea. DESIGN: Retrospective, observational study using serial cross-sectional data. SETTING: The National Patient Samples of the Korean Health Insurance Review & Assessment Service from 2011 to 2018 were used. PARTICIPANTS: A total of 31 059 patients with fibromyalgia were included in this study. The basic characteristics of the patients were stratified by sex, age and comorbidity. A patient was considered to have a condition if it was recorded as a principal diagnosis at least once in a year. PRIMARY AND SECONDARY OUTCOME MEASURES: Trends in the types of medical visits and prescribed treatments were investigated and the values are presented as rates per 100 patients. The types of pharmacological treatment were presented according to the existing clinical guidelines. Additionally, combination prescription trends and associated characteristics were investigated. RESULTS: Of the patients, 66.2% were female. Visits to internal medicine departments showed the most significant increase (2011: 11.34; 2018: 21.99; p<0.001). Non-pharmacological treatment rates declined (physical therapy 2011: 18.11; 2018: 13.69; p<0.001, acupuncture 2011: 52.03; 2018: 30.83; p<0.001). Prescription rates increased for analgesics, relaxants, antiepileptics and antidepressants. Non-steroidal anti-inflammatory drug prescriptions had the highest increase (2011: 27.65; 2018: 40.02; p<0.001). Serotonin-norepinephrine reuptake inhibitor prescriptions showed significant growth (2011: 2.4; 2018: 8.05; p<0.001). Prescription durations were generally longer for women (p<0.001), with higher rate increases in this group. Combinations of ≥3 medication classes increased (2011: 8.2; 2018: 9.64; p=0.041). Women were more likely to receive combination prescriptions (crude OR 1.47 (95% CI 1.29 to 1.68), adjusted 1.18 (95% CI 1.03 to 1.36)). CONCLUSIONS: Our findings provide basic reference data for the development and application of national guidelines for fibromyalgia.

Assessment of complementary and alternative medicine methods in the management of ankylosing spondylitis, rheumatoid arthritis, and fibromyalgia syndrome.

A wide variety of musculoskeletal, arthritic, connective tissue, and vasculitic diseases fall under the umbrella of "rheumatic diseases". Ankylosing spondylitis, rheumatoid arthritis, and fibromyalgia syndrome are the three members of this disease group with relatively high prevalence. Pharmacological options are at the center of therapeutic algorithms in treating rheumatic diseases, particularly in reducing inflammation. Despite significant advances in pharmacological treatment in recent years, achieving complete treatment success in a group of patients is impossible. Therefore, patients with rheumatic diseases frequently utilize alternative treatment options, such as complementary and alternative medicine. Complementary and alternative medicine is a broad category of health practices not part of the leading health system. Patients with rheumatic diseases turn to complementary and alternative medicine for various reasons, including restricted access to some treatments due to high prices and rigorous regulations, worries about drug side effects, and symptoms that continue despite pharmacological treatment. In addition, because complementary and alternative medicine options are considered natural, they are frequently accepted as well tolerated and have few harmful effects. Ankylosing spondylitis, rheumatoid arthritis, and fibromyalgia syndrome are the primary foci of this comprehensive review. First, we attempted to summarize the non-traditional physical medicine and complementary and alternative medicine options that can be utilized to manage these diseases. Second, we addressed the link between exercise and inflammation in rheumatic diseases. We briefly discussed the possible benefits of exercise-based approaches. In addition, we highlighted the benefits of cooperation between rheumatology and physical medicine-rehabilitation clinics.

Cost analysis of chronic pain due to musculoskeletal disorders in Chile.

The magnitude of the cost of chronic pain has been a matter of concern in many countries worldwide. The high prevalence, the cost it implies for the health system, productivity, and absenteeism need to be addressed urgently. Studies have begun describing this problem in Chile, but there is still a debt in highlighting its importance and urgency on contributing to chronic pain financial coverage. This study objective is to estimate the expected cost of chronic pain and its related musculoskeletal diseases in the Chilean adult population. We conducted a mathematical decision model exercise, Markov Model, to estimate costs and consequences. Patients were classified into severe, moderate, and mild pain groups, restricted to five diseases: knee osteoarthritis, hip osteoarthritis, lower back pain, shoulder pain, and fibromyalgia. Data analysis considered a set of transition probabilities to estimate the total cost, sick leave payment, and productivity losses. Results show that the total annual cost for chronic pain in Chile is USD 943,413,490, corresponding an 80% to the five diseases studied. The highest costs are related to therapeutic management, followed by productivity losses and sick leave days. Low back pain and fibromyalgia are both the costlier chronic pain-related musculoskeletal diseases. We can conclude that the magnitude of the cost in our country's approach to chronic pain is related to increased productivity losses and sick leave payments. Incorporating actions to ensure access and financial coverage and new care strategies that reorganize care delivery to more integrated and comprehensive care could potentially impact costs in both patients and the health system. Finally, the impact of the COVID-19 pandemic will probably deepen even more this problem.

Meaning of patient global assessment when joint counts are low in rheumatoid arthritis.

OBJECTIVE: In patients with rheumatoid arthritis (RA) with low 28-joint tender and swollen joint counts but who assessed their disease as active, to evaluate whether activity reflected RA symptoms. METHODS: We carried out a cross-sectional study of patients in BRASS, a cohort of patients with established RA who had 28-joint counts assessed, scored their disease activity, identified their painful joints, and answered questions about other sites of pain and fatigue. Patients and their rheumatologists were asked about the presence of fibromyalgia. We examined whether patients reported pain in joints excluded from the 28-joint joint count (feet, ankles, hips, neck) and pain or symptoms probably unrelated to RA including low back pain, headache and fibromyalgia. Fatigue was not classified. Analyses were descriptive. RESULTS: Of 272 patients, 49 had tender and swollen joint counts <1 and a patient global assessment score of ≥3/10. 48/49 (95%) reported pain in joints excluded from the 28-joint count. Of these 49, 24 (45%) also had other symptoms especially low back pain. Fatigue was present in all patients. No patient had fibromyalgia. CONCLUSION: If joint counts <=1 are scored in 28 joints, patient global assessments of ≥3/10 often occur when there is pain in uncounted joints, joints that may respond to RA treatment.

Telemedicine in the Management of Patients with Rheumatic Disease during COVID-19 Pandemic: Incidence of Psychiatric Disorders and Fibromyalgia in Patients with Rheumatoid Arthritis and Psoriatic Arthritis.

The management of patients with immuno-rheumatological diseases has profoundly changed during the COVID-19 pandemic and telemedicine has played an important role in the disease follow-up. In addition to monitoring disease activity and any adverse events, especially infectious events, assessing the psychological situation of the patient can be fundamental. Furthermore, COVID-19 has a serious impact on mental health and, since the beginning of the pandemic, a significantly higher incidence of anxiety disorders and depressive symptoms especially in younger people was observed. In this study, we evaluated the incidence of depressive disorders, anxiety, and fibromyalgia (FM) in our patients with rheumatoid arthritis and psoriatic arthritis during the lockdown period due to the COVID-19 pandemic and we validate the use of telemedicine in the clinical management of these patients. Mental and physical stress during the COVID-19 pandemic can greatly worsen FM symptoms and intensify patients' suffering without a clinical flare of the inflammatory disease for patients affected by rheumatoid arthritis. Telemedicine has allowed us to identify patients who needed a face-to-face approach for therapeutic reevaluation even if not related to a flare of the inflammatory disease. Even if our data does not allow us to draw definitive conclusions regarding the effectiveness of telemedicine as greater than or equal to the standard face-to-face approach, we continue to work by modifying our approach to try to ensure the necessary care in compliance with safety and, optimistically, this tool will become an important part of rheumatic disease management.

[Assessment of secondary fibromyalgia in patients with rheumatoid arthritis or spondylarthritis]. / Évaluation de la fibromyalgie secondaire à la polyarthrite rhumatoïde ou la spondylarthrite.

Pain is one of the main factors assessed in most of the scores used to measure activity in rheumatoid arthritis (RA) and spondylo arthritis (SpA). However, the experience of pain is complex, subjective and influenced by many factors. Fibromyalgia (FM) is present in 16-38% of patients with inflammatory rheumatic diseases (IRD) and has been shown to significantly increase indices of disease activity, often preventing an adequate response to immunosuppressive treatments. Recognition of secondary FM is important to avoid overtreatment. This article explores the relationship between FM and IRD, and how to optimise the assessment and treatment of one in the presence of the other.

La douleur est l'un des principaux facteurs évalués dans la plupart des scores utilisés pour mesurer l'activité de la polyarthrite rhumatoïde (PR) et des spondylarthrites (SpA). Cependant, l'expérience de la douleur est complexe, subjective et influencée par de nombreux facteurs. La fibromyalgie (FM) est présente chez 16 à 38 % des patients atteints de maladies rhumatismales inflammatoires (MRI) et il a été démontré qu'elle augmente de manière significative les indices d'activité de la maladie, empêchant souvent une réponse adéquate aux traitements immunosuppresseurs. La reconnaissance de la FM secondaire est importante pour éviter le surtraitement. Cet article explore la relation entre la FM et les MRI, et comment optimiser l'évaluation et le traitement de l'une en présence de l'autre.

An Assessment of Naturopathic Treatments, Health Concerns, and Common Comorbid Conditions in Fibromyalgia Patients: A Retrospective Medical Record Review.

Background: Fibromyalgia (FM) is characterized by chronic pain, with allodynia and hyperalgesia being the most common signs. Many patients with FM explore, express interest, and use complementary and alternative medicine to help manage symptoms and improve quality of life. However, little is known about the clinical recommendations provided by naturopathic doctors (NDs). Objective: To describe trends in assessment and treatment of patients with FM by NDs. Methods: Retrospectively, medical records of 200 patients with the FM ICD-10 code were reviewed from the Robert Schad Naturopathic Clinic. Of these records, 70 met inclusion criteria and were further analyzed. Comorbid conditions, health concerns, physical and psychological examinations, and treatment were recorded. Patients were excluded if informed consent for research was not signed. The project was approved by the Research Ethics Board of the Canadian College of Naturopathic Medicine. Results: Seventy patients met criteria and were included in the current analysis. Most patients identified as female (96%). Vitamin D (57%), magnesium (54%), omega-3 fish oil (53%), acupuncture by an acupuncturist (53%) or an ND (40%), B12 orally or by injection (40%), and probiotics (40%) were highly utilized treatments. A past/current medical history of digestive complaints (64%) and depression/mental illness (63%) were common comorbidities, alongside a history of arthritic conditions (53%) and anxiety (43%). A family history of arthritic conditions (47%) was also prevalent. The Widespread Pain Index and Symptom Severity tool (43%) was used to assess pain and other symptoms. No adverse effects of treatment were readily identifiable. Conclusion: Findings from this study reveal elements of both consistency and variability in the treatment recommendations from NDs in a teaching clinic environment. Future research that assesses or compares treatment recommendations for FM in other settings may be informative to better understand health services, the nature of individualized care, and patient experiences.

Juvenile Fibromyalgia in Patients With Juvenile Idiopathic Arthritis: Utility of the Pain and Symptom Assessment Tool.

OBJECTIVE: To evaluate the proportion of children with juvenile idiopathic arthritis (JIA) who met criteria for comorbid juvenile fibromyalgia (FM) using the Pain and Symptom Assessment Tool (PSAT), and to identify clinical and demographic differences among JIA patients with and without juvenile FM. METHODS: Patients ages 11-17 years with JIA were recruited from 4 North American pediatric rheumatology centers. Each patient completed the PSAT. Additional clinical and disease activity measures included pain visual analog scale, patient global assessment of disease activity (PtGA) and physician global assessment of disease activity (PhGA), the Functional Disability Inventory (FDI), and the Pain Catastrophizing Scale in children. RESULTS: Of 129 patients, 11 met criteria for juvenile FM. FDI scores were markedly higher in patients who tested positive for juvenile FM, with a mean of 24.8 compared to 6.9 in patients without juvenile FM (P < 0.001). Pain catastrophizing scores were also significantly higher, by ~14 points, in patients with juvenile FM. There was a significant tendency for patients to give higher disease activity scores than physicians, which was more marked among patients with juvenile FM. In patients with juvenile FM, PtGA scores exceeded PhGA scores by a mean of 3.7, compared to a mean of 0.7 among patients without juvenile FM (P < 0.001). CONCLUSION: A minority of JIA patients (8.5%) met criteria for juvenile FM. This group demonstrated markedly more functional impairment. PtGA scores were strikingly higher than PhGA scores among patients with JIA who met juvenile FM criteria, suggesting that providers might consider a more expansive approach to chronic pain and non-musculoskeletal symptom assessment and treatment in JIA patients.

Cardiovascular risk assessment using ASCVD risk score in fibromyalgia: a single-centre, retrospective study using "traditional" case control methodology and "novel" machine learning.

BACKGROUND: In autoimmune inflammatory rheumatological diseases, routine cardiovascular risk assessment is becoming more important. As an increased cardiovascular disease (CVD) risk is recognized in patients with fibromyalgia (FM), a combination of traditional CVD risk assessment tool with Machine Learning (ML) predictive model could help to identify non-traditional CVD risk factors. METHODS: This study was a retrospective case-control study conducted at a quaternary care center in India. Female patients diagnosed with FM as per 2016 modified American College of Rheumatology 2010/2011 diagnostic criteria were enrolled; healthy age and gender-matched controls were obtained from Non-communicable disease Initiatives and Research at AMrita (NIRAM) study database. Firstly, FM cases and healthy controls were age-stratified into three categories of 18-39 years, 40-59 years, and ≥ 60 years. A 10 year and lifetime CVD risk was calculated in both cases and controls using the ASCVD calculator. Pearson chi-square test and Fisher's exact were used to compare the ASCVD risk scores of FM patients and controls across the age categories. Secondly, ML predictive models of CVD risk in FM patients were developed. A random forest algorithm was used to develop the predictive models with ASCVD 10 years and lifetime risk as target measures. Model predictive accuracy of the ML models was assessed by accuracy, f1-score, and Area Under 'receiver operating Curve' (AUC). From the final predictive models, we assessed risk factors that had the highest weightage for CVD risk in FM. RESULTS: A total of 139 FM cases and 1820 controls were enrolled in the study. FM patients in the age group 40-59 years had increased lifetime CVD risk compared to the control group (OR = 1.56, p = 0.043). However, CVD risk was not associated with FM disease severity and disease duration as per the conventional statistical analysis. ML model for 10-year ASCVD risk had an accuracy of 95% with an f1-score of 0.67 and AUC of 0.825. ML model for the lifetime ASCVD risk had an accuracy of 72% with an f1-score of 0.79 and AUC of 0.713. In addition to the traditional risk factors for CVD, FM disease severity parameters were important contributors in the ML predictive models. CONCLUSION: FM patients of the 40-59 years age group had increased lifetime CVD risk in our study. Although FM disease severity was not associated with high CVD risk as per the conventional statistical analysis of the data, it was among the highest contributor to ML predictive model for CVD risk in FM patients. This also highlights that ML can potentially help to bridge the gap of non-linear risk factor identification.

[What are the epidemiological characteristics of patients with work incapacity as a result of fibromyalgia who return to work?] / ¿Qué características epidemiológicas tienen los pacientes con fibromialgia e incapacidad laboral que se reincorporan a un puesto de trabajo?

OBJECTIVE: To ascertain what epidemiological variables determine whether a patient with work incapacity as a result of fibromyalgia returns to work. MATERIAL AND METHODS: A retrospective cohort study was carried out that included 412 patients with fibromyalgia under 54 years of age and classified as having a total permanent disability by the National Institute of Social Security in Madrid in 2005. Follow-up from 2005 to 2019. We studied the variables of age, sex, marital status, CFS/MCS, psychiatric diagnosis, type of social security affiliation, occupation (CNO-11) and economic amount of the disability benefit in euros/month (4 tranches are established of <500, 500-750, 750-1000 and> 1000). We analyse the impact of these variables on return to work using a binary logistic regression model. RESULT: The mean age was 45+/-7. A total of 44% did not return to another job. The variables that were significant in the multivariate study were age (OR 0.93, CI 0.90 - 0.97), association with CFS and/or MCS (OR 0.07, CI 0.02 - 0.24), occupation (OR 0, 82; IC 0.73 - 0.92) and the amount of the disability benefit (OR 0.26; IC 0.19 - 0.35). CONCLUSION: The probability of returning to another job decreases with age (1.07 times for each year), as the amount of the disability benefit increases (3.85 times for each successive tranche), as the level of qualification required for the occupation decreases (1.21 times for each successive CON-11 code) or if there is CFS and/or MCS (12.9 times).

High cost of illness in fibromyalgia patients in Iran, irrespective of disease severity: A prospective cost study.

AIMS: This study aimed to estimate the economic burden of fibromyalgia (FM) in 6 months, using a cost-diary, and to evaluate its relationship with the disease severity. METHODS: This is a prospective cost-of-illness study on 62 participants with an FM diagnosis within a 6 month period. Patients completed the questionnaires, including FIQR (Revised Fibromyalgia Impact Questionnaire) and SF-12 (12-item short-form survey). The cost-diary method was used to track the cost of the disease. The participants received six cost-diary booklets during the study period to report their FM-related costs, hours, and days of productivity loss. The final costs are reported in US dollars. RESULTS: Most of the participants were women (90.3%) with a mean (±SD) age of 40.80 (±5.50) years and a mean (±SD) FIQR score of 54.38 (±14.13). Moreover, 45.2% of patients fulfilled all six booklets, whereas 24.2% returned only one booklet. The participants showed a mean (±SD) direct healthcare, non-healthcare, and indirect cost of $ 2817.08 (±$ 1860.04), $ 1497.98(±$ 1358.21), and $ 1449.05(±$ 3637.41) per patient for 6 months, respectively. CONCLUSION: Fibromyalgia is associated with high health-related and non-health-related costs in our country, irrespective of its severity. This study warrants urgent consideration in managing the disease burden on both patients and society.

ASAS Health Index in patients with spondyloarthritis and its association with disease activity and disease burden including fibromyalgia.

OBJECTIVES: To evaluate the association of the Assessment of Spondyloarthritis international Society Health Index (ASAS-HI) with disease activity and disease burden in patients with spondyloarthritis (SpA). METHODS: Observational, cross-sectional and single-centre study from the Córdoba AxSpA Task force, Registry and Outcomes (CASTRO). Scores related to disease activity (BASDAI and ASDAS), functionality (BASFI), structural damage, mobility, health and the presence of concomitant fibromyalgia (FM) were obtained from all patients. ASAS-HI score was considered the main outcome. Pearson's r statistic, Student's t test, and univariate and multivariate linear regressions were performed to assess the association between the ASAS-HI score and the studied covariates. RESULTS: A total of 126 SpA patients were included. The mean ASAS-HI score was 4.6±3.9, showing a "strong" positive linear correlation (r>0.60) with the BASDAI and BASFI and a "moderate" positive linear correlation (r=0.40 to 0.60) with the global VAS and ASDAS. Patients with FM showed a significantly higher ASAS-HI score than patients without FM (9.5±3.2 vs. 3.7±3.4, respectively, p<0.01). Multiple linear regression showed that 57.4% of the ASAS-HI variability (R2=0.574) was explained by the presence of concomitant FM (ß=2.23, 95% CI 0.73 to 3.80, p=0.004), higher scores on the BASDAI (ß=0.62, 95% CI 0.25 to 0.97, p=0.001) and BASFI (ß=0.57, 95% CI 0.26 to 0.88, p=0.001). CONCLUSIONS: The impairment of health in patients with SpA was mainly associated with high disease activity, worsening functionality and with the presence of a possible concomitant FM. Therefore, in patients with high ASAS-HI scores we must evaluate the presence of concomitant FM.

Adult attention deficit hyperactivity disorder in patients with fibromyalgia syndrome: Assessment and disabilities.

In the broader list of cognitive concerns, neuropsychological testing has shown that attentional impairment may have a specific burden in Fibromyalgia Syndrome (FMS). Preliminary observations have reported a subset of FMS patient screened for attention disorders fulfilling the actual diagnosis of ADHD, a neurodevelopmental disorder characterized by developmentally inadequate levels of inattention, hyperactivity and impulsivity that might persist in adulthood. Yet, no study to date has systematically examined the history and the specific contribution of ADHD to FMS in terms of clinical impact and related specific disabilities. In this study, 106 individuals with a FMS diagnosis based on the 2010 criteria of the American College of Rheumatology have been assessed for (a) the presence of ADHD; (b) the burden of disability caused by ADHD versus FMS; (c) the presence of other psychiatric disorders. Results indicated that ADHD was present in 24.5% of FMS individuals, it was associated with higher FMS symptoms severity and a greater functional impairment, particularly in the work/school domain. Moreover, patients with both FMS and ADHD had higher frequency of substance use disorders than those with FMS only (38.5% versus 3.8%) and mainly opioids. Overall, results suggest that ADHD can increase burden adding specific disability in work and social activities, and it is associated with a trend for the excessive use of opioid painkillers. Detection of neurodevelopmental and actual symptoms of ADHD is highly recommended especially in patient prone to increase the dose of anti-pain medication.

Difficult-to-treat rheumatoid arthritis: contributing factors and burden of disease.

OBJECTIVES: Treatment of difficult-to-treat (D2T) RA patients is generally based on trial-and-error and can be challenging due to a myriad of contributing factors. We aimed to identify risk factors at RA onset, contributing factors and the burden of disease. METHODS: Consecutive RA patients were enrolled and categorized as D2T, according to the EULAR definition, or not (controls). Factors potentially contributing to D2T RA and burden of disease were assessed. Risk factors at RA onset and factors independently associated with D2T RA were identified by logistic regression. D2T RA subgroups were explored by cluster analysis. RESULTS: Fifty-two RA patients were classified as D2T and 100 as non-D2T. Lower socioeconomic status at RA onset was found as an independent risk factor for developing D2T RA [odds ratio (OR) 1.97 (95%CI 1.08-3.61)]. Several contributing factors were independently associated with D2T RA, occurring more frequently in D2T than in non-D2T patients: limited drug options because of adverse events (94% vs 57%) or comorbidities (69% vs 37%), mismatch in patient's and rheumatologist's wish to intensify treatment (37% vs 6%), concomitant fibromyalgia (38% vs 9%) and poorer coping (worse levels). Burden of disease was significantly higher in D2T RA patients. Three subgroups of D2T RA patients were identified: (i) 'non-adherent dissatisfied patients'; (ii) patients with 'pain syndromes and obesity'; (iii) patients closest to the concept of 'true refractory RA'. CONCLUSIONS: This comprehensive study on D2T RA shows multiple contributing factors, a high burden of disease and the heterogeneity of D2T RA. These findings suggest that these factors should be identified in daily practice in order to tailor therapeutic strategies further to the individual patient.

Fibromyalgia: Prevalence and Burden of Disease Among Active Component Service Members, U.S. Armed Forces, 2018.

This report uses routinely collected data in the Defense Medical Surveillance System (DMSS) to characterize the prevalence and burden of fibromyalgia (FM) among members of the active component of the U.S. Armed Forces between 1 Jan 2018 and 31 Dec 2018. During the study period, the prevalence of FM was 0.15%. There was a trend of increasing prevalence with increasing age. Prevalence was highest among women (0.59%), those in the oldest age group (0.52%), non-Hispanic blacks (0.25%), those in the Air Force (0.21%),those in a healthcare occupation (0.36%), senior enlisted (0.24%) and warrant officers (0.24%). The prevalence of FM was approximately twice as high among non-Hispanic blacks compared to non-Hispanic whites. The average number of medical encounters per FM patient per year was 57 (median 38, LQ=21, UQ=66, range=1-263) compared to an average of 13 in the total patient population. The groups of conditions most commonly associated with an FM diagnosis were musculoskeletal and mental health conditions.The burden of FM disease poses clear readiness and retention concerns.

Identifying co-morbid fibromyalgia in patients with systemic lupus erythematosus using the Multi-Dimensional Health Assessment Questionnaire.

OBJECTIVE: Fibromyalgia (FM) is prevalent but often under-recognized in patients with systemic lupus erythematosus (SLE). Patient-reported outcomes (PROs) from the Multi-Dimensional Health Assessment Questionnaire (MDHAQ) can identify co-morbid FM in patients with rheumatic diseases. The present study examined the utility of the MDHAQ in recognizing FM in patients with SLE during routine consultations. METHODS: Patients with SLE completed an MDHAQ. FM status was determined by the validated 2016 revision of the ACR 2010/2011 preliminary FM criteria. Individual PROs from the MDHAQ and composite Fibromyalgia Assessment Tool (FAST) indices of the discriminatory PROs were compared between patients with and without FM using Student's unpaired t-test and receiver operating characteristic curve analysis to determine the area under the curve (AUC). The physician's clinical impression of FM was recorded, and the SLE Disease Activity Index was used to assess disease activity. RESULTS: Of 88 patients with SLE, 23 (26%) satisfied the 2016 FM criteria. The FAST3 composite measure of two out of three of pain (≥6/10), joint count (≥16/48) and symptom checklist (≥16/60) correctly classified 89% of patients (AUC=0.90, kappa=0.71). Physician diagnosis demonstrated moderate agreement with the 2016 FM criteria (kappa=0.43) but missed 43% of patients with FM. In the presence of active disease, the FAST3 correctly classified 91% of patients. CONCLUSIONS: Co-morbid FM is prevalent in SLE yet often underdiagnosed by physicians. The simple FAST3 index of the MDHAQ provides an easy-to-use self-reported tool to improve identification of FM in patients with SLE.

Syrian female war refugees: preliminary fibromyalgia and insomnia screening and treatment trends.

BACKGROUND: Fibromyalgia (FM) is a chronic disorder characterised by chronic widespread pain, fatigue and sleep disturbances with higher prevalence in females. Psychological factors contribute largely to FM. Although women war refugees represent a fragile population that is prone to psychological distress, FM was not studied in this population. OBJECTIVE: The current study had three objectives: (1) to screen FM and insomnia prevalence and severity, (2) to study the correlation between FM severity and insomnia and (3) to study FM treatment trends and their concordance with the guidelines among female Syrian refugees residing in Jordan. METHODS: A cross-sectional study design was performed. Data from 384 Syrian female were analysed from four medical centres in Jordan. The Fibromyalgia Impact Questionnaire (FIQ) was used to study FM prevalence. Structured questions were designed to explore FM pharmacotherapeutic trend, and the Insomnia Severity Index (ISI) was used to screen insomnia. RESULTS: The prevalence of severe FM was about (30%), with a significant correlation with insomnia. Acetaminophen was used for FM relief in 60% of the study sample. CONCLUSIONS: Fibromyalgia prevalence is high among female refugees and is associated with insomnia. The treatment is suboptimal. The early screening and raising awareness of FM diagnosis and treatments are highly recommended. Key Points Fibromyalgia is an overlooked disorder especially among female war refugees The prevalence of severe fibromyalgia was about (30%), with a significant correlation with insomnia Fibromyalgia among the Syrian female refugees is mistreated perhaps due to lack of the proper diagnosis.