Residential combustion of coal: Effect of the fuel and combustion stage on emissions.

Worldwide coal is still used for household heating purposes not only because it is available and cheap but also due to behavioural issues. Regional variability in fuels and combustion appliances make accurate emission estimates from this source hard to achieve. In the present study, gaseous (CO, VOCs, SO2 and NOX) and particulate matter (TSP) emission factors (EFs) were determined for Spanish household coal combustion covering three commercial coals and distinct combustion stages and mimicking usage patterns in real households. TSP samples were analysed to determine water-soluble inorganic ions, metal(loid)s, and organic and elemental carbon (OC and EC). Additionally, the morphology of the emitted particles was also characterised. CO (3.43-169 g kg-1), NOX (1.29-6.00 g kg-1) and SO2 (8.96-22.3 g kg-1) EFs showed no trend regarding the combustion stage or coal type tested. On the other hand, VOC, TSP and EC EFs were higher for the ignition/devolatilisation combustion stage, regardless of the fuel tested. TSP EFs (0.085-1.08 g kg-1) increased with increasing coal volatile matter while the opposite trend was recorded for VOC emissions (0.045-3.39 gC kg-1). TSP carbonaceous matter was dominated by EC while OC represented a small fraction of the particulate mass emitted (less than 8 %wt.). Inorganic compounds composed an important fraction of the TSP samples. Sulphate particulate mass fractions (8.66-22.9 %wt.) appeared to increase with coal S-content. Coal combustion released particles with diverse morphologies, including silicate-rich particles, ferro- and glassy-spheres. This study provides novel emission factors to update emission inventories of residential coal combustion. Additionally, detailed chemical profiles were obtained for source apportionment.

Links between aerosol radiative forcing and rain characteristics: Stratiform and convective precipitation.

The radiative forcing before and after rain events was studied between 12 February 2016 and 14 March 2017 in León, Spain. For this purpose, the radiative forcing fluxes were calculated using the Radiative Transfer Model Global Atmospheric ModEl (RTM GAME). After the application of a set of selection criteria (based on the availability of AERONET data, rain characteristics and lightning maps), 16 stratiform rain events were identified, concentrated in spring and winter, and 15 convective rain events were found concentrated in spring and summer. Rainfall events were grouped according to the atmospheric forcing (ΔFATM) before rain: "low" or "high" (lower or higher than 30 W m-2). The threshold has been set at this value because it is the mean ΔFATM of all the selected events before rain. There were significant statistical differences between stratiform and convective events in rain duration, mean raindrop diameter and parameters a and b of radar reflectivity Z and rainfall intensity R relationship (Z = a Rb). When comparing "low" and "high" groups, raindrop diameter was similar in stratiform (0.51 ± 0.08 vs 0.48 ± 0.12 mm) and convective events (0.96 ± 0.98 vs 0.83 ± 0.63 mm), registering higher values for the latter. In stratiform events, the rain scavenging effect on aerosol particles is clearly observed in the "high" group with a decrease of radiative forcing of -27.0 ± 25.3%, and to a lesser extent, in the "low" group, probably because of a lower aerosol load in the atmosphere. In stratiform events, the mode of the raindrop size gamma distribution presented statistical differences between "low" (0.25 ± 0.13 mm) and "high" (0.35 ± 0.05 mm) groups. We claim that this points towards a relationship between radiative forcing before rain and the specific characteristics of rainfall measured at ground level. This study increases our knowledge on the important role of rainwater as a clean agent of the atmosphere and its impact on climate (through radiative forcing).

Evolution of size-segregated aerosol concentration in NW Spain: A two-step classification to identify new particle formation events.

Real-time measurements of particles in the 15-736 nm range have been obtained by a Scanning Mobility Particle Sizer to characterize the evolution of particle size distribution and new particle formation (NPF) events in an urban background area. The annual, weekly and diurnal variations of the modal (nucleation (Nnuc), Aitken (NAit) and accumulation (Nacc)) particle concentrations were characterised. The NAit and Nacc registered their maximums in cold months during rush hours, in the morning (0600-0900 UTC) and in the afternoon (1700-2000 UTC), while the maximums for Nnuc were reached in warm months during midday hours. NAit, Nacc and Ntotal showed a significant negative correlation with wind speed and a different relationship with the planetary boundary layer (PBL) height by periods. In the warm period, a positive significant correlation between PBL and Nnuc was registered, indicating that the higher dispersion promoted by a high PBL causes favourable conditions for the occurrence of NPF events (a low polluted atmosphere). NPF processes are one of the main sources of ultrafine particles (<100 nm) in the warm period. After a visual-based classification, 45 NPF events of type Ia (strong and with a good confidence level) were identified and analysed, occurring primarily between 1100 and 1500 UTC, mainly in spring and summer. In addition, a two-step method was developed for identifying NPF events: cluster analysis followed by discriminant analysis. The application of discriminant analysis to one of the clusters, grouping 93 days, enabled us to identify 55 of the 56 NPF events days included in the cluster. This method is a valuable tool for identifying NPF events quickly and effectively.

Scavenging of submicron aerosol particles in a suburban atmosphere: The raindrop size factor.

This paper studies the below-cloud scavenging caused by precipitation on ultrafine and accumulation modes, as well as the role of the different raindrop sizes in an urban environment. The equipment used to measure aerosol particles and raindrop variables includes a scanning mobility particle sizer spectrometer-SMPS and a Laser Precipitation Monitor (LPM), respectively. An analysis of the scavenging efficiency and the scavenging coefficient (λ) by modes and rain intensities was carried out. The main results observed have been: i) the nucleation (between 14 and 30 nm), Aitken (between 30 and 100 nm), accumulation 1 (between 100 and 300) and accumulation 2 (between 300 and 1000 nm) modes presented a scavenging efficiency of 15, 4, 22 and 21%, respectively; ii) events with rain intensities between 1 and 3 mm h-1 caused less scavenging in all modes; iii) raindrop sizes between 1.25 and 3.5 mm scavenged mainly particle sizes between 70 and 250 nm. Lower scavenging was observed on particle sizes >300 nm, and particle sizes >600 nm were only scavenged by raindrop sizes >4.75 mm; iv) the respirable fraction before and after the rain events presented a statically significant decrease of -35%. The combination in this study of SMPS and disdrometer measurements has resulted in a more detailed characterization of the influence of this process on the submicrometer aerosol fraction, noting that below-cloud scavenging is one of the main removal pathways for submicrometer aerosol particles. This study thus contributes to improving the current state of knowledge of below-cloud scavenging.

Chemical composition of rainwater under two events of aerosol transport: A Saharan dust outbreak and wildfires.

A one-year campaign of joint sampling of aerosols and precipitation, carried out in León, Spain, allowed to study the impact of two special events that affected the air quality in the north of the country, on rainfall in the city: a period with wildfires and a Saharan dust intrusion. The wildfires that occurred in northern Portugal and northwestern Spain in August 2016 affected the chemistry of rainfall on 15 August 2016, causing an increase in concentrations of NH4+, Na+, Cl-, K+, Mg2+, Ca2+, SO42- and NO3- and in the concentrations of organic acids, which was reflected in the levels of soluble and insoluble organic carbon. This led to acidification of rainwater (pH = 4.8). The second precipitation event was registered between 11 and 14 February 2017, during which the rainwater was collected in four daily fractions (P1, P2, P3 and P4). The rain sample of 12 February (P2) coincided with a Saharan dust intrusion that reached northern Iberia that day. The chemical composition of P2 showed an increase in the Ca2+ (>800%), Mg2+ (71%), Cl- (62%), and SO42- (33%) concentrations, with respect to P1. The input of crustal elements to the atmosphere helped to neutralize the P2 rainwater, causing pH values higher than 6.5. Once the dust intrusion left the north of the Peninsula, the composition of rainwater P3 and P4 revealed a mixture of marine contribution with local anthropogenic emissions, as well as a decrease in ion concentrations and conductivity, and an increase in pH values.

Aethalometer measurements in a road tunnel: A step forward in the characterization of black carbon emissions from traffic.

A sampling campaign was conducted in the Liberdade Avenue tunnel (Braga, Portugal) during a week (with 56,000 vehicles) to monitor black carbon (eBC-equivalent black carbon) by means of an Aethalometer AE-31, and gaseous pollutants (CO2, CO, NOx). Inside the tunnel, the mean eBC mass concentration was 21 ±â€¯10 µg m-3, reaching a maximum hourly value of 49.0 µg m-3. An hourly and weekday-weekend study was carried out. Regarding the Absorption Ångström exponent (AAE), a mean value of 0.97 ±â€¯0.10 was obtained, for a source of practically pure traffic. There was a positive significant correlation between eBC and the number of light vehicles (r = 0.47; p < 0.001) and between eBC and the gaseous emissions: CO (r = 0.67; p < 0.001), CO2 (r = 0.71; p < 0.001), NO (r = 0.63; p < 0.001) and NO2 (r = 0.70; p < 0.001). The mean black carbon emission factors (EFBC) inside the tunnel were 0.31 ±â€¯0.08 g (kg fuel)-1 and 0.11 ±â€¯0.08 mg veh-1 km-1, similar to those found in other studies for gasoline and diesel vehicles in road tunnels.

Unusual winter Saharan dust intrusions at Northwest Spain: Air quality, radiative and health impacts.

Saharan air masses can transport high amounts of mineral dust particles and biological material to the Iberian Peninsula. During winter, this kind of events is not very frequent and usually does not reach the northwest of the Peninsula. However, between 21 and 22 February 2016 and between 22 and 23 February 2017, two exceptional events were registered in León (Spain), which severely affected air quality. An integrative approach including: i) typical synoptic conditions; ii) aerosol chemical composition; iii) particle size distributions; iv) pollen concentration; v) aerosol optical depth (AOD); vi) radiative forcing and vii) estimation of the impact of aerosols in the respiratory tract, was carried out. In the global characterization of these events, the exceedance of the PM10 daily limit value, an increase in the coarse mode and a rise in the iron concentration were observed. On the 2016 event, an AOD and extinction-related Ångström exponent clearly characteristic of desert aerosol (1.1 and 0.05, respectively) were registered. Furthermore, pollen grains not typical of flowering plants in this period were identified. The chemical analysis of the aerosol from the 2017 event allowed us to confirm the presence of the main elements associated with mineral sources (aluminum, calcium, and silica concentrations). An increase in the SO42-, NO3- and Cl- concentrations during the Saharan dust intrusion was also noted. However, in this event, there was no presence of atypical pollen types. The estimated dust radiative forcing traduced a cooling effect for surface and atmosphere during both events, corroborated by trends of radiative flux measurements. The estimated impact on the respiratory tract regions of the high levels of particulate matter during both Saharan dust intrusions showed high levels for the respirable fraction.

Quantification of source specific black carbon scavenging using an aethalometer and a disdrometer.

Aerosol black carbon (BC) is the second strongest contributor to global warming, after CO2, and it is linked to many adverse health effects. A sampling campaign of 15 months was carried out in León (Spain) in order to evaluate the scavenging of BC with an ensemble aethalometer-disdrometer. The aethalometer provides the concentration of equivalent black carbon (eBC), and the disdrometer, the raindrop size distribution. A total of seventy-five rain events were studied and in 73% of them there was an effective (eBCinitial > eBCfinal) scavenging, with a mean decrease of 48 ±â€¯37% in long rain events (>8 h) and 39 ±â€¯38% in short rain events. The scavenging of BC is strongly related to its source. Thus, the scavenging coefficient (SC) mean value of the BC from fossil fuel (eBCff) for short and long rain events was 5.1 10-5 and 1.3 10-5 s-1, respectively. For the BC from biomass burning (eBCbb), the SC values were 1.6 10-4 and 2.8 10-5 s-1 in short and long events, respectively. There was a significant positive correlation between the SC and the number of drops with diameters between 0.375 and 2.5 mm. Rain scavenging of eBC was analyzed depending on the air mass origin obtaining an effective scavenging for air masses from Atlantic, Arctic and Africa. A linear model (R2 = 0.72) was built to estimate the ΔeBC values with variables from an aethalometer, a disdrometer and a weather station: eBC concentration before rain, swept volume and precipitation accumulated. A Kolmogorov-Smirnov statistical test confirmed the goodness of fit of the model to the measured data.

Impact of the wood combustion in an open fireplace on the air quality of a living room: Estimation of the respirable fraction.

Presently, both in rural areas and in cities open fireplaces are still present and large quantities of wood are combusted every year. The present study aims to characterize aerosol size distribution, chemical composition and deposition in the human respiratory tract of particles emitted during the combustion of logs of oak in an open fireplace installed in the living room of a typical village house. CO2 and CO levels and aerosol size distribution have been continuously monitored and a PM10 sampler with two types of filters for chemical and microscopic analysis was also installed. The increment, between the operating periods and the indoor background, in the organic carbon and PM10 concentration due to the use of the fireplace is 15.7±0.6 (mean±standard deviation) and 58.5±6.2µgm-3, respectively. The two main polluting processes during the operation of the fireplace are the ignition with the subsequent refueling and the final cleaning of the residual ashes. In both phases mean values around 1800 particles cm-3 with CMD of 0.15µm were measured. However, while PM10 levels of 130±120µgm-3 were estimated for the ignition stage, values of 200±200µgm-3 were obtained during the final cleaning step. Assessment conducted according to ISO standard 7708:1995, demonstrated that a person who stays in a living room when an open fireplace is lit will inhale, on average, 217µgm-3 and 283µgm-3 during the ignition and the refueling stages, respectively. Subsequent refueling proved to be much less polluting. The ashes removal can also be very polluting and dangerous to health if there are hidden small incandescent embers among the ashes (estimated PM10 of 132µgm-3), reaching a CO2 level of 1940ppm and a dangerous level of CO of 132ppm.

Hemodynamics of the pectinis oculi artery in American pekin ducks (Anas platyrhynchos domestica).

OBJECTIVE: To measure blood velocity parameters of the main detectable branch of the pectinis oculi artery and compare with values found in other arteries in other species to form a hypothesis of the function of the pecten oculi in birds. METHODS: Eleven American pekin ducks (Anas platyrhynchos domestica) without ocular diseases were examined with ocular Doppler ultrasonography. The pectinate artery resistive index (RI) and pulsatility index (PI) were calculated. RESULTS: The mean of RI and PI values resulted, respectively, in: left eye (0.43 ± 0.07; 0.58 ± 0.13), right eye (0.37 ± 0.09; 0.47 ± 0.14), and both eyes (0.40 ± 0.08; 0.53 ± 0.14). DISCUSSION: The low RI and PI values found in the main branch of the pectinis oculi artery compared with other arteries in other tissues suggest a high metabolic activity in the pecten oculi, and it could indicate a nutritional function and/or intraocular pressure regulation.

Los médicos de familia y el tratamiento del tabaquismo en la consulta de Atención Primaria / The family physicians and smoking cessation treatment in the Primary Care Clinics

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GH/IGF1 axis disturbances in the fibromyalgia syndrome: is there a rationale for GH treatment?

Fibromyalgia Syndrome (FMS) is a frequent idiopathic condition in which patients experience intense pain in specific tender points, profound fatigue and sleep disturbances. Although pain had not account so far in growth hormone deficiency syndrome (GHD) description, symptoms of FMS are very similar; and there is strong evidence of decreased GH secretion at least in a subset of FMS patients. Is there an overlap of the two diseases? A systematic Medline/Embase search for preliminary proof-of-concept trials, but also larger placebo-controlled studies, have shown that GH replacement in low-IGF1 patients can significantly improve some symptoms of FMS and quality of life, suggesting a direct causal effect of GH deficiency. Despite the use of relatively high doses of GH in these patients, treatment seems to be well tolerated. Several mechanisms of action for GH in FMS relief have been suggested, including both central modulation of pain and peripheral musculo-tendinous effects, as already described in classic GHD.

Pregnancy and orthotopic liver transplantation.

BACKGROUND: Sexual and reproductive abnormalities affect up to 50% patients with terminal liver failure. However, these functions recover quickly after orthotopic liver transplantation (OLT). Thus, 80%-90% of OLT women of childbearing age recover menstruation within a few months after transplantation. The aim of our study was to analyze the impact of pregnancy among liver transplant recipients at our center, as well as to analyze the effects of immunosuppression on the fetus. METHODS: From April 1986 to April 2011, we performed 1500 OLT in 1341 recipients. Among these recipients, 18 patients (1.2%) become pregnant during the follow-up. RESULTS: The most frequent causes of terminal liver failure were as follows: chronic parenchymal disease (n = 9; 50%), cholestatic disease (n = 3; 16.6%), acute liver failure (n = 5; 27.7%), and metabolic disease (n = 1; 5.5%) The average recipient age at the beginning of pregnancy was 21.2 (±7.3) years. Sixteen patients (88%) became pregnant beyond a year after OLT. The 30 pregnancies in our study resulted in the following: newborns alive (NBA; n = 20; 66.6%) abortions (n = 8; 26.6%) or fetal deaths (n = 2; 6%). The most common immunosuppressant used during pregnancy was tacrolimus (75%) followed by cyclosporine (25%). There were no maternal deaths during pregnancy or the postpartum period. DISCUSSION: We did not observe significant differences between immunosuppression type and maternal complications, pregnancy duration, and childbirth type. Although pregnancy is potential risk, the literature and our results suggest that at a year or more after OLT it usually is safe and successful.

Everolimus monotherapy or combined therapy in liver transplantation: indications and results.

INTRODUCTION: Everolimus is a potent immunosuppressant with several advantages over calcineurin inhibitors, such as good tolerance, preventive effects on cardiovascular morbidity, and mortality and cancer prevention as it inhibits cell proliferation. PATIENTS AND METHODS: Between April 1986 and December 2010, we performed 1500 liver transplants (OLT) in 1341 recipients, including 57 patients who were prescribed everolimus 24 (42.1%) as monotherapy and 33 (57.9%) as treatments combined with other immunosuppressants. We performed a retrospective analysis of our experience with conversion to everolimus in OLT recipients. RESULTS: The 43 men and 14 women had a mean overall age at transplantation of 59.1 ± 10 years. The most frequent indication for OLT was hepatocellular carcinoma (HCC; 53.8%). Everolimus was introduced to prevent HCC recurrence (53%), development of de novo tumors (33%), address renal dysfunction (7%), or overcome side effects of other immunosuppressants (7%). We observed a significant improvement in renal function using the estimated glomerular filtration rate (Crockcroft-Gault formula) from 68.5 mL/min before to 74.5 mL/min after switching to everolimus. The 72% of recipients who developed ≥1 adverse event, most frequently showed hyperlipidemia (34.4%). CONCLUSION: Both monotherapy and combined everolimus regimens were well-tolerated immunosuppressive regimens in liver transplant recipients with recurrent or de novo malignancies. Everolimus improved renal function. The most common side effects were hyperlipidemia, edema, and mouth ulcerations, which were well controlled with anti-lipidemic agents or decreased everolimus dosages.

Liver transplantation from anti-hepatitis C virus-positive donors: our experience.

BACKGROUND: Hepatitis C (HCV) is among the most common causes of end-stage liver disease worldwide. The donor shortage leads us to consider alternative organ sources such as HCV-positive donors. The outcomes of these transplants must be evaluated thoroughly since there is universal recurrence of disease among HCV-positive liver transplant recipients. METHODS: From January 2005 to April 2011, we performed 143 liver transplants (OLT) to treat end-stage liver disease secondary to HCV infection. Thirteen patients (9,1%) received livers from HCV-positive donors. A control group consisted of 130 HCV-positive patients who underwent OLT during the same period with organs from HCV-negative donors. Donor HCV status was assessed by 2 tests: HCV antibodies and viral load. Not only recipient and graft survivals were analyzed, but also frequency, timing and severity of hepatitis recurrence. RESULTS: Among 143 transplants performed in HCV-positive recipients during a 6-year period from January 1, 2005, to April 30, 2011, 9.1% of patients received an organ from an anti-HCV-positive donor, 72.7% of whom showed a negative viral load. The vast majority (80%) of our patients suffered hepatitis during their follow-up, 22.4% of which were severe cases. CONCLUSIONS: No significant difference in patient or graft survival was observed between the 2 groups. A high percentage of grafts with initial positive serology for HCV showed no viral replication. Grafts from HCV-positive donors can be considered to be a safe, effective source for liver donation.

Growth hormone treatment for sustained pain reduction and improvement in quality of life in severe fibromyalgia.

Functional defects in growth hormone (GH) secretion and its efficacy as a complementary treatment have been suggested for fibromyalgia. This study investigated the efficacy and safety of low-dose GH as an add-on therapy in patients with both severe FM and low insulin-like growth factor 1 levels. A total of 120 patients were enrolled in a multicenter, placebo-controlled study for 18 months. They were randomly assigned to receive either 0.006 mg/kg/day of GH subcutaneously (group A, n=60) or placebo (group B, n=60) for 6 months (blind phase). The placebo arm was switched to GH treatment from month 6 to month 12 (open phase), and a follow-up period after GH discontinuation was performed until month 18. Standard treatment for fibromyalgia (selective serotonin re-uptake inhibitors, opioids, and amitriptyline) was maintained throughout the study. Number and intensity of tender points, Fibromyalgia Impact Questionnaire (FIQ) with its subscales, and EuroQol 5 dimensions test (EQ5D) with visual analogue scale (VAS) were assessed at different time points. At the end of the study, 53% of group A patients obtained fewer than 11 positive tender points, vs 33% of group B patients (P<.05). 39.1% vs 22.4% reached more than 50% improvement in VAS (P<.05). Group A patients showed significantly improved FIQ scores (P=.01) compared with group B. Although GH discontinuation worsened all scores in both groups during follow-up, impairment in pain perception was less pronounced in the GH-treated group (P=.05). In this largest and longest placebo-controlled trial performed in FM (NCT00933686), addition of GH to the standard treatment is effective in reducing pain, showing sustained action over time.

High prevalence of growth hormone deficiency in severe fibromyalgia syndromes.

CONTEXT: Fibromyalgia (FM) is characterized by widespread pain and fatigue and is considered a syndrome with different pathogenic mechanisms. Controversial data on GH axis disturbances have been published. Some preliminary trials have shown promising effects of GH therapy on tender points and quality of life in FM. AIM: The aim was to study the patterns of GH secretion/sensitivity in a cohort of severe FM patients. SETTING: The study was conducted in five tertiary hospitals. METHODS: A total of 493 FM women (1990 American College of Rheumatology criteria) recruited from five centers, having more than 16 tender points, Fibromyalgia Impact Questionnaire scores above 75, more than 1 yr of stable medication (serotonin reuptake inhibitors, amitriptyline, and opioids), and body mass index below 35 kg/m(2) underwent baseline IGF-I/GH determinations; an insulin tolerance test (ITT) and a modified IGF-I generation test were performed in those cases showing IGF-I of 150 microg/liter or less. RESULTS: A total of 169 of the 493 patients (34.2%) showed IGF-I of 150 microg/liter or less. Mean peak GH during ITT was 13.3 +/- 9.9 ng/ml in 127 patients in which the test was performed. In 22 of 127 (17.3%), ITT peak GH was 5 microg/ml or less, and in eight of them (6.3%), the peak GH was 3 ng/ml or less. Mean baseline GH (n = 127) was 1.47 +/- 2.58 ng/dl, and eight of 120 (6.8%) showed an insufficient IGF-I response (<50% over baseline) to the IGF-I generation test. CONCLUSION: FM patients show a high prevalence of GH axis dysfunction. A significant number of patients show biochemical patterns of GH deficiency as well as some degree of GH resistance and might be potential candidates for substitution treatment.

Amitriptyline in the treatment of fibromyalgia: a systematic review of its efficacy.

The objective of this study was to assess the efficacy and safety of amitriptyline as a treatment of FM. A comprehensive computerized search in Medline (Pubmed), EMBASE and The Cochrane Library was performed. Randomized controlled trials (RCTs) comparing amitriptyline vs placebo in adult patients suffering from FM were identified, the methodological quality was assessed and the results of the main outcomes were evaluated. Ten RCTs were identified. Large clinical variability and statistical heterogeneity precluded quantitative meta-analysis. Overall, the study quality was moderate to high. Amitriptyline 25 mg/day (six RCTs) demonstrated a therapeutic response compared with placebo in the domains of pain, sleep, fatigue and overall patient and investigator impression. This benefit was generally seen at 6-8 weeks of treatment but no effect was noted at 12 weeks. Amitriptyline 50 mg/day (four RCTs) did not demonstrate a therapeutic effect compared with placebo. Neither dose of amitriptyline had an effect on tender points count. No clear statements on adverse events with amitriptyline can be made due to inconsistencies in data among the studies. A definitive clinical recommendation regarding the efficacy of amitriptyline for FM symptoms cannot be made. There is some evidence to support the short-term efficacy of amitriptyline 25 mg/day in FM. There is no evidence to support the efficacy of amitriptyline at higher doses or for periods >8 weeks. More stringent RCTs with longer follow-up periods are required to determine the long-term efficacy and safety of the amitriptyline and define its role in the multidisciplinary management of FM.