EULAR revised recommendations for the management of fibromyalgia.

OBJECTIVE: The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies meant that most recommendations were 'expert opinion'. METHODS: A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological/non-pharmacological management for fibromyalgia. A review, in May 2015, identified eligible publications and key outcomes assessed were pain, fatigue, sleep and daily functioning. The Grading of Recommendations Assessment, Development and Evaluation system was used for making recommendations. RESULTS: 2979 titles were identified: from these 275 full papers were selected for review and 107 reviews (and/or meta-analyses) evaluated as eligible. Based on meta-analyses, the only 'strong for' therapy-based recommendation in the guidelines was exercise. Based on expert opinion, a graduated approach, the following four main stages are suggested underpinned by shared decision-making with patients. Initial management should involve patient education and focus on non-pharmacological therapies. In case of non-response, further therapies (all of which were evaluated as 'weak for' based on meta-analyses) should be tailored to the specific needs of the individual and may involve psychological therapies (for mood disorders and unhelpful coping strategies), pharmacotherapy (for severe pain or sleep disturbance) and/or a multimodal rehabilitation programme (for severe disability). CONCLUSIONS: These recommendations are underpinned by high-quality reviews and meta-analyses. The size of effect for most treatments is relatively modest. We propose research priorities clarifying who will benefit from specific interventions, their effect in combination and organisation of healthcare systems to optimise outcome.

Health priorities in an Australian mining town: an intercept survey.

INTRODUCTION: In developed countries men's health is poorer than women's for a range of key indicators, and being an Indigenous man in Australia widens the gap substantially. Establishing the rates of mortality and health inequality between the sexes is useful for identifying that men's health needs attention and Indigenous men need particular attention. Men's health-seeking behaviour has been suggested as one of the causes of poor outcomes. This study aimed to identify differences in health concerns between men and women, and Indigenous and non-Indigenous people in an Australian mining town with the aim of targeting health promotion activities more effectively. METHODS: An intercept survey was conducted of residents of the Pilbara region towns Port Hedland and South Hedland in 2010. Settings included the main shopping centres and precincts in the towns and at community event venues. Interviewers recorded gender, age, Aboriginal or Torres Strait Islander self-identification status, whether people worked in the mining industry or not and in what capacity and occupation. Participants were asked a series of questions about health issues of concern from a list of 13 issues which included national and local health priorities. They were then asked to prioritise their choices. RESULTS: Three hundred and eighty participants completed the survey, 48% were male; 18.4% identified as an Indigenous person and 21% worked in the local mining industry. Men's and women's health priorities were generally similar but women prioritised 'sick kids' as their number one priority and men prioritised heart disease (χ² =28.75 df=12 p = 0.004). More than half of the Aboriginal men identified diabetes as a priority (53%) compared with the non-Aboriginal men (24%). This was significantly different (χ²=10.04 df=1 p = 0.002). Approximately one-third of Aboriginal women identified alcohol misuse as a priority (32.4%) compared with non-Aboriginal women (6%). This was also significantly different (χ²= 19.45 df=1 p = 0.001). CONCLUSION: Health promotion in the Pilbara region needs to be re-evaluated for areas such as injury prevention, which remains the commonest cause of hospitalisations after renal dialysis, yet is a low health priority in the community mindset, especially among Indigenous people.

EULAR evidence-based recommendations for the management of fibromyalgia syndrome.

OBJECTIVE: To develop evidence-based recommendations for the management of fibromyalgia syndrome. METHODS: A multidisciplinary task force was formed representing 11 European countries. The design of the study, including search strategy, participants, interventions, outcome measures, data collection and analytical method, was defined at the outset. A systematic review was undertaken with the keywords "fibromyalgia", "treatment or management" and "trial". Studies were excluded if they did not utilise the American College of Rheumatology classification criteria, were not clinical trials, or included patients with chronic fatigue syndrome or myalgic encephalomyelitis. Primary outcome measures were change in pain assessed by visual analogue scale and fibromyalgia impact questionnaire. The quality of the studies was categorised based on randomisation, blinding and allocation concealment. Only the highest quality studies were used to base recommendations on. When there was insufficient evidence from the literature, a Delphi process was used to provide basis for recommendation. RESULTS: 146 studies were eligible for the review. 39 pharmacological intervention studies and 59 non-pharmacological were included in the final recommendation summary tables once those of a lower quality or with insufficient data were separated. The categories of treatment identified were antidepressants, analgesics, and "other pharmacological" and exercise, cognitive behavioural therapy, education, dietary interventions and "other non-pharmacological". In many studies sample size was small and the quality of the study was insufficient for strong recommendations to be made. CONCLUSIONS: Nine recommendations for the management of fibromyalgia syndrome were developed using a systematic review and expert consensus.

Structure of the catalytic domain of fibroblast collagenase complexed with an inhibitor.

Collagenase is a zinc-dependent endoproteinase and is a member of the matrix metalloproteinase (MMP) family of enzymes. The MMPs participate in connective tissue remodeling events and aberrant regulation has been associated with several pathologies. The 2.4 angstrom resolution structure of the inhibited enzyme revealed that, in addition to the catalytic zinc, there is a second zinc ion and a calcium ion which play a major role in stabilizing the tertiary structure of collagenase. Despite scant sequence homology, collagenase shares structural homology with two other endoproteinases, bacterial thermolysin and crayfish astacin. The detailed description of protein-inhibitor interactions present in the structure will aid in the design of compounds that selectively inhibit individual members of the MMP family. Such inhibitors will be useful in examining the function of MMPs in pathological processes.

Lack of effect of amitriptyline in murine myotonia.

Amitriptyline, a tricyclic antidepressant, has been reported to diminish signs of human myotonic muscular dystrophy, but has not been examined in other myotonias. Normal and myotonic (ADRmto) mice were injected acutely with either amitriptyline, phenytoin, procainamide or 0.9% saline. In addition, two groups of myotonic mice were injected chronically with either 0.9% saline or amitriptyline for 28 days. Behavior, assessed before injection using a "drop test," was re-evaluated at 30-min intervals for up to 180 min postinjection, as well as at the end of the 28-day chronic trial. If improvement in behavior was noted, the mice were then evaluated with insertional needle electromyography (EMG) and in vitro contractility (maximal tetanic tension and relaxation time) studies. Neither acute nor chronic amitriptyline administration had any beneficial effect on behavior, EMG or contractile parameters in myotonic mice. Phenytoin abolished abnormal EMG activity and improved behavior. Procainamide improved behavior and contractility parameters but had no effect on EMG. These results confirm that the myotonic mouse is responsive to classic antimyotonic agents, but not to amitriptyline.

Electromyographic and nerve conduction studies in the mdx mouse.

Electromyographic responses to needle-electrode insertion and repetitive indirect stimulation were recorded from gastrocnemius, soleus and cranial tibialis muscles of normal and dystrophic (mdx) mice at 20-154 days. Recordings from myotonic (ADRmto) mice served as controls for "true" myotonia. Complex repetitive discharges were observed in muscles of mdx mice but no complex repetitive discharges or other abnormalities were observed in muscles of normal control mice. Complex repetitive discharges in mdx muscles did not resemble the prolonged, abnormally repetitive discharges observed in myotonic mouse muscles. Neuromuscular blockade with tubocurarine and nerve transection had no effect on observed electromyographic abnormalities in the mdx mice. Nerve conduction and repetitive stimulation studies also revealed no abnormalities in mdx mice. These findings indicate that the mdx condition is a nonmyotonic, primary myopathy. No signs of myotonia or impaired neuromuscular transmission were found in mdx mice.

BIP-Bender protocols of learning disabled and regular education students.

20 learning disabled and 20 normal elementary school children took the Bender Visual-Motor Gestalt Test twice, once under standard conditions and again using Background Interference Procedure paper. Based on Koppitz's scoring system, the disabled pupils did equally poorly on both modes but performed significantly worse than the normal children when given the standard Bender first. No other differences were found. Other scoring methods are suggested for investigation.

Glucocorticoids in muscular dystrophy: beneficial effects of dexamethasone on avian myopathy.

A corticosteroid with mixed glucocorticoid-mineralocorticoid actions was previously shown to improve neuromuscular function in muscular dystrophic chickens. The significance of that finding was recently underscored by reports that a mixed-action corticosteroid improved muscle function in Duchenne dystrophy patients, albeit at high doses. In the present study a pure glucocorticoid improved function and retarded muscle histopathology in the chicken, but a pure mineralocorticoid did not. These observations suggest that elucidation of mechanisms by which glucocorticoids beneficially affect dystrophic muscle could lead to development of more effective therapies.