Predicting acupuncture efficacy in fibromyalgia: results of a pragmatic open-label study.

OBJECTIVES: To identify the predictive factors of treatment response to acupuncture in patients with fibromyalgia (FM). METHODS: Patients with FM refractory to standard drug therapy underwent eight weekly acupuncture sessions. Significant improvement, defined as a reduction of at least 30% of the revised Fibromyalgia Impact Questionnaire (FIQR), was assessed at the end of the eight weeks (T1) of treatment and three months after the end of treatment (T2). Univariate analysis was conducted to identify predictors of significant improvement at T1 and T2. Variables that resulted to be significantly associated with clinical improvement at univariate analysis were included in multivariate models. RESULTS: Analyses were conducted on 77 patients (9 males, 11.7%). At T1, significant improvement in FIQR was recorded in 44.2% of patients. At T2, persistent significant improvement was recorded in 20.8% of patients. In the multivariate analysis, predictive variables of treatment failure were tender point count (TPC) (odds ratio [OR] =0.49, 95% confidence interval [95% CI]: 0.28-0.86, p=0.01) and pain magnification (OR=0.68, 95% CI: 0.47-0.99, p=0.04) assessed with the Pain Catastrophising Scale, at T1. At T2, the only predictive variable of treatment failure was concomitant duloxetine use (OR=0.21, 95% CI: 0.05-0.95, p=0.04). CONCLUSIONS: High TPC and a tendency for pain magnification predict immediate treatment failure, while duloxetine therapy predicts it three months after completion of the acupuncture course. The identification of clinical characteristics of unfavourable response to acupuncture could help to implement a cost-effective prevention of treatment failure in FM.

Impact on clinical outcome of follow-up blood cultures and risk factors for persistent bacteraemia in patients with gram-negative bloodstream infections: a systematic review with meta-analysis.

BACKGROUND: The clinical usefulness of follow-up blood cultures (FUBCs) in gram-negative bloodstream infections (GN-BSIs) represents a debated issue. OBJECTIVE: To assess the impact on the clinical outcome of FUBCs in patients with GN-BSI and to predict risk factors for persistent bacteraemia. DATA SOURCES: PubMed-MEDLINE, Scopus, and the Cochrane Library Database were independently searched until 24 June, 2022. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials, prospective, or retrospective observational studies, including patients affected by GN-BSIs. Primary endpoints were in-hospital mortality rate, and persistent blood stream infections were defined as FUBC-positive for the same pathogen isolated from index blood cultures (BCs). PARTICIPANTS: Hospitalized patients with documented GN-BSIs. INTERVENTION: Performance of FUBCs (defined as subsequent BCs collected at least 24 hours after index BCs). ASSESSMENT OF RISK OF BIAS: Quality of included studies was independently assessed according to the Cochrane Risk of Bias Tool and the Risk Of Bias In Non-randomized Studies of Interventions. METHODS OF DATA SYNTHESIS: Meta-analysis was performed by pooling odds ratio (OR) retrieved from studies providing adjustment for confounders using random-effect model with the inverse variance method. Risk factors for persistent blood stream infections were also assessed. RESULTS: A total of 3747 articles were screened, and 11 observational studies (6 assessing impact on outcome (N = 4631), and 5 investigating risk factors for persistent GN-BSI (N = 2566)), conducted between 2002 and 2020 were included. The execution of FUBCs was associated with a significantly lower risk of mortality (OR, 0.58; 95% CI, 0.49-0.70; I2 = 0.0%). The presence of end-stage renal disease (OR, 2.99; 95% CI, 1.77-5.05), central venous catheter (OR, 3.30; 95% CI, 1.82-5.95), infections due to extended-spectrum ß-lactamase-producing strains (OR, 2.25; 95% CI, 1.18-4.28), resistance to empirical treatment (OR, 2.70; 95% CI, 1.65-4.41), and unfavourable response at 48 hours (OR, 2.99; 95% CI, 1.44-6.24) emerged as independent risk factors for persistent bacteraemia. CONCLUSIONS: The execution of FUBCs is associated with a significantly low risk of mortality in patients with GN-BSIs. Our analysis could be useful to stratify patients at a high risk of persistent bacteraemia to optimize the use of FUBCs.

Evaluation of trace calls by Xpert MTB/RIF ultra for clinical management in low TB burden settings.

BACKGROUND: Clinical interpretation of trace results by Xpert MTB/RIF Ultra assay (Ultra) used as an initial diagnostic test for tuberculosis (TB) may be challenging. The aim of the study was to evaluate the frequency and epidemiology of trace readouts in routine clinical practice in a low TB prevalence setting and to propose guidance on how to manage patients with trace calls considering the data available (clinical, radiological, bacteriological etc.). MATERIALS AND METHODS: A retrospective, observational, monocentric study was conducted at IRCCS Azienda Ospedaliero-Universitaria of Bologna, Italy between November 2017-December 2020. Presumptive TB patients with at least one Ultra trace result during diagnostic workup before treatment were included in the study. Patients with ongoing anti-TB treatment at the time of the trace call result or with no clinical data available were excluded from the study. RESULTS: Fifty-nine presumptive TB patients with Ultra trace readouts were included in the study (mean age 37.0 years, 61% males). Four patients had a history of TB in the last 2 years. Twenty-five (42.4%) of the 59 samples with trace results were respiratory material. 57/59 (96.6%) patients started anti-TB treatment soon after obtaining trace results, based on clinical, radiological or other information available, while for two patients with a recent history of TB the trace result did not lead to anti-TB treatment. Culture was positive for M. tuberculosis for 31/59 (52.5%) samples with trace calls: 13/25 (52.0%) were respiratory samples and 18/33 (54.5%) non-respiratory samples. The clinical and/or radiological findings of 47/57 (82.4%) patients given anti-TB therapy improved during treatment. CONCLUSION: In low TB incidence settings, Ultra trace calls in presumptive TB patients should be considered as true-positive and treatment should be started promptly, except in cases of recent history of TB, where careful evaluation of other diagnostic criteria is necessary before starting anti-TB treatment. A decisional algorithm for clinical management is proposed.

Treatment duration for central line-associated infection caused by Enterococcus spp.: a retrospective evaluation of a multicenter cohort.

Objective of this study was to assess the appropriate treatment duration for enterococcal central line-associated bloodstream infections (CLABSIs). This observational, retrospective, multicenter study conducted between 2011 and 2019 enrolled all hospitalized patients with monomicrobial enterococcal CLABSI. Those with infective endocarditis and non-survivors at least 7 days from index blood culture (BC) were excluded. Primary endpoint was 30-day mortality. We enrolled 113 patients, of whom 59% were male, median age was 64 (SD ± 15) and median Charlson's index score 5 (IQR 3-8). Enterococcus faecalis and Enterococcus faecium were found in 51% and 44% of cases, respectively. Median treatment duration was 11 days (IQR 6-17), and 32% of patients (n = 36) received ≤ 7 days. Characteristics of patients receiving more or less than 7 days of treatment were similar. Central line was removed in 82% (n = 93) of cases within a median of 3 days (1-8). At both uni- and multivariate analysis, duration of antibiotic treatment > 7 days was not associated with 30-day mortality [HR 0.41 (95% CI, 0.13-1.24), p = 0.12] even after adjustment with propensity score [HR 0.47 (95% CI 0.17-1.26), p = 0.13]. A 7-day treatment course appears to be safe in non-complicated enterococcal CLABSIs.

Risk factors for persistent enterococcal bacteraemia: a multicentre retrospective study.

OBJECTIVES: Conditions favouring persistent enterococcal bacteraemia (p-EB) have not been fully investigated yet. The aim of our study is to analyse risk factors for p-EB and its impact on mortality. METHODS: International two-centre retrospective study of all hospitalised adults with enterococcal bacteraemia managed with follow-up blood cultures (BCs) during the period 2011-2019. Exclusion criteria were: (1) death within 72 hours from index BCs and (2) polymicrobial bacteraemia. Primary endpoint was p-EB, defined as further isolation of the same species of Enterococcus spp. from BCs after at least 72 hours of appropriate antibiotic therapy. Multivariable logistic regression model was performed to assess risk factors for p-EB. The impact of p-EB on 30-day mortality was assessed by Kaplan-Meier survival curve and Cox regression multivariable model. RESULTS: During the study period, 244 enterococcal bacteraemia were diagnosed. P-EB were 13.5% (33/244). At multivariable analysis, factors independently associated with p-EB were hematologic malignancy (OR 4.60 [95% CI 1.32-16.00], P = 0.01), infective endocarditis (OR 7.99 [95% CI 2.20-28.9], P = 0.002), and use of daptomycin as initial treatment (OR 4.50 [95% CI 1.29-15.61], P = 0.018). Mortality rate was higher in the p-EB group (32% vs. 18%). Kaplan-Meier survival curve showed that patients with p-EB were less likely to survive at 30 days from index BCs (log-rank P = 0.002). Using a Cox regression model, independent predictors of 30-day mortality were hematologic malignancy (HR 2.30 [95% CI 1.02-4.11], P = 0.043), p-EB (HR 1.93 [95% CI 0.92-4.04], P = 0.08), and septic shock (HR 5.92 [95% CI 2.17-16.30], P = 0.001). CONCLUSION: P-EB was diagnosed mainly in very fragile patients and in those receiving daptomycin as frontline therapy. P-EB may have an impact on mortality.

Pain Changes Induced by Acupuncture in Single Body Areas in Fibromyalgia Syndrome: Results from an Open-Label Pragmatic Study.

To date, there is considerable evidence of the effectiveness of acupuncture in fibromyalgia syndrome (FM). However, it is not known in which body areas acupuncture is more effective. The objective of this study was to assess the improvements of pain induced by acupuncture in single body areas in patients with FM. In this open-label pragmatic study, FM patients in a state of high disease severity were consecutively enrolled and treated with a course of 8 weekly sessions of manual acupuncture. Patients were assessed with the Self-Administered Pain Scale (SAPS) of the Fibromyalgia Assessment Status at baseline and at the end of eight acupuncture sessions. Acupuncture sessions were all conducted with the same acupuncture formula (LV3, SP6, ST36, LI4, CV6, CV12, Ex-HN-3, and GV20) in each session and in each patient. Ninety-six FM patients completed the course of treatment. All the 16 body areas assessed by SAPS showed improvement in pain. A statistically significant improvement was achieved in 12 of the 16 body areas investigated, with the best results in abdomen and forearms (p = 0.001), while the worst results were registered for neck (p = 0.058), chest (p = 0.059), left buttock (p = 0.065), and right thigh (p = 0.052). The treatment has also shown significant effectiveness in improving fatigue and sleep quality (p < 0.0001). Acupuncture has a beneficial effect on pain in all body areas in FM patients with high disease severity, with the greatest effects in the abdominal region and in the forearms, allowing a personalization of the treatment.

Mild cognitive impairment in psoriatic arthritis: Prevalence and associated factors.

ABSTRACT: To assess the prevalence and factors associated with mild cognitive impairment (MCI) in patients suffering from psoriatic arthritis (PsA).A cross-sectional evaluation was conducted in consecutive PsA patients. Sociodemographic data and the clinimetric variables related to PsA and psoriasis were collected for each patient. MCI was assessed through the Montreal Cognitive Assessment (MoCA). The cognitive performance of PsA patients was compared to healthy subjects using one-way analysis of variance (ANOVA). The correlations among variables were studied by the Spearman rank correlation coefficient. A multivariate logistic regression analysis was carried out to establish the predictors of MCI.The study involved 96 PsA patients and 48 healthy subjects. MCI (defined as a MoCA score < 26/30) was detected in 47 (48.9%) PsA patients. Compared to healthy subjects, the MoCA score resulted significantly lower in PsA patients (P = .015). The main differences involved the denomination and language domains. MoCA was negatively correlated with age (r = -0.354; P < .0001), HAQ-DI (r = -0.227; P = .026), and fatigue (r = -0.222; P = .029), and positively correlated with psoriasis duration (r = 0.316; P = .001) and DLQI (r = 0.226; P = .008).The multivariate logistic regression analysis revealed the duration of psoriasis (P = .0005), age (P = .0038), PASI (P = .0050), and HAQ-DI (P = .0193) as predictors of the MoCA score.MCI is present in a significant proportion of PsA patients, and is mainly determined by age, cutaneous variables, and disability.

Rosuvastatin decreases serum inflammatory markers and slows atherosclerosis progression rate in treated HIV-infected patients with metabolic syndrome.

OBJECTIVES: Metabolic syndrome (MetS) is usually associated in general population with systemic inflammation and higher cardiovascular risk, but data about the effect of statins in patients with HIV infection and MetS are lacking to date. METHODS: Prospective cohort study of treated HIV-infected patients, aged from 40 to 60 years, with or without MetS, who started rosuvastatin (10 mg daily), and were followed-up for 12 months. The primary endpoint was change in serum levels of high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), and tumour necrosis factor-α (TNF-α). The secondary endpoint was change in the carotid intima-media thickness (IMT). RESULTS: One hundred and twenty-five patients were enrolled: 61 with MetS (MetS group) and 64 without MetS (control group). After 12 months, rosuvastatin produced a significant decrease in mean serum levels of hsCRP (-0.28 mg/dL; p = .037), IL-6 (-2.1 pg/mL; p = .018) and TNF-α (-6.3 pg/mL; p = .004) in patients with MetS. On the contrary, in controls rosuvastatin did not lead to a significant change in mean levels of all biomarkers. After 12 months, the mean IMT increase at the carotid bifurcation was significantly lower in the MetS group than in the control group at the carotid bifurcation (0.017 vs. 0.031 mm; p = .037) and in all other anatomical sites. CONCLUSION: Our findings suggest that rosuvastatin is effective in reducing serum inflammation markers and slowing atherosclerosis progression rate in HIV-infected patients on cART and with MetS, while its effects on serum biomarkers and IMT increase seem to be negligible in those without MetS.

SARS-CoV-2 related pneumonia in an adult with cystic fibrosis: natural favourable clinical course or effective therapy?

We report the case of a man affected by cystic fibrosis who developed a severe SARS-CoV-2 related pneumonia in March 2020. In addition to lopinavir/ritonavir and hydroxychloroquine, he was treated with two doses of tocilizumab, displaying a significant clinical improvement. This is the first case described in the literature of an adult patient affected by cystic fibrosis who received tocilizumab for COVID-19, with documented total recovery, also assessed by a spirometry.

Acupuncture for Fibromyalgia: An Open-Label Pragmatic Study on Effects on Disease Severity, Neuropathic Pain Features, and Pain Catastrophizing.

The treatment of fibromyalgia syndrome (FMS) is still far from being optimally coded, and pharmacological strategies are often unsatisfactory. Acupuncture plays a role among nonpharmacological intervention approaches; however, there is still no clarity as to when to integrate it into therapy. The objective of this study is to explore the role of acupuncture, in terms of efficacy on main disease severity measures and pain features, in patients with nonresponsive disease, defining nonresponsive FMS characterized by a revised Fibromyalgia Impact Questionnaire (FIQ-R) ≥39 and a Patient Health Questionnaire 15-item (PHQ15) ≥5 despite optimal drug therapy. Patients were treated with weekly sessions, for a total of eight acupuncture sessions. At the baseline and at the end of the treatment cycle, a comprehensive clinical evaluation was carried out to evaluate improvements in terms of disease severity and impact on neuropathic pain features (measured with the painDETECT questionnaire (PDQ)) and pain catastrophizing (measured with the Pain Catastrophizing Scale (PCS)). At the end of the eight-week treatment, patients experienced a significant improvement in all evaluated parameters (for FIQ-R, PDQ, and PHQ15 p < 0.0001, for PCS p=0.001). Of particular note is the effectiveness on manifestations that are difficult to treat such as neuropathic pain features and on negative psychological perceptions such as pain catastrophizing. It can be stated that acupuncture can be proposed also in phases of high severity of disease. Intervention with multimodal strategies, including acupuncture, could be of great benefit to patients.

A proposal on how to assess the weight of the subjective components of the DAPSA in patients with psoriatic arthritis and comorbid fibromyalgia syndrome.

OBJECTIVES: To establish the weight of the subjective components of the Disease Activity index for Psoriatic Arthritis (DAPSA) in psoriatic arthritis (PsA) patients and comorbid fibromyalgia syndrome (FM). METHODS: In PsA patients not fulfilling the DAPSA remission, it has been calculated the DAPSA-patient (DAPSA-P), an index represented by the ratio between the sum of the subjective components (tender joint count+patient global assessment of disease activity+visual analogue scale pain) and DAPSA in its entirety (swollen joint count+tender joint count+patient global assessment of disease activity+visual analogue scale pain+C-reactive protein [in mg/ dl]). The DAPSA-P ranges from 0 to 1, and values closer to 1 suggest a major weight of the subjective components, while values closer to 0 indicate a greater contribution of the swollen joint count and C-reactive protein, the two factors more closely related to inflammation. It was also defined as the presence of a comorbid FM, and it was established the DAPSA-P cut-off point distinguishing for the presence of a comorbid FM through the receiver operating characteristic (ROC) curve analysis. RESULTS: DAPSA-P was higher in all PsA+FM patients. Analysing the receiver operating characteristic curve, the DAPSA-P cut-off distinguishing a comorbid FM was 0.775. CONCLUSIONS: DAPSA-P can help to measure how comorbid FM inflates DAPSA.

Development and validation of the SImple FIbromyalgia Screening questionnaire for improving the recognition of fibromyalgia in daily practice.

OBJECTIVES: To develop and test in a preliminary way a new self-administered and user-friendly screening tool, called SImple FIbromyalgia Screening (SIFIS) questionnaire, to screen Italian speaking patients for the presence of fibromyalgia (FM). METHODS: The development of the SIFIS questionnaire followed five steps: identification of a specific patient population, item pool development, item reduction, test of the provisional questionnaire, and validation study. The item generation was carried out by a review of the literature on the existing questionnaires. Thirty-three items were identified, and a survey was performed among 139 specialists. The frequency importance product allowed us to select the six most significant items. The validation study allowed the determination of sensitivities, specificities and likelihood ratios (LRs) aiming to calculate the post-test probability of the presence of FM, by applying the Bayesian Analysis Model method. RESULTS: The preliminary testing was performed in 284 subjects with multi-site pain. In 230 (80.9%) of them, FM was diagnosed according to the modified 2010 American College of Rheumatology (ACR) criteria. For each of the six items, LRs varied between 3.37 and 5.00. The best positive LR was found in item 1, exploring persistent pain. The presence of four out of six items gave a post-test probability ≥80% (range: 81.8-87.1%). CONCLUSIONS: The SIFIS questionnaire is a useful tool that can be used for potential screening.

The application of dual-energy computed tomography in the diagnosis of musculoskeletal disorders: a review of current concepts and applications.

With the assistance of innovations in scanner engineering and software design, dual-energy computed tomography (DECT) is an advanced imaging method that has been developed over the last decade. With its unique ability to differentiate materials by their atomic number, DECT has opened new perspectives in imaging. The principal advantages of DECT over conventional CT in the musculoskeletal setting relate to the additional information provided regarding tissue composition, artifact reduction and image optimization. In musculoskeletal imaging, uric acid material decomposition images can help identify articular deposition of uric acid crystals (in addition to the detection of uric acid renal stones). Material separation can also help detect bone marrow edema on CT in the case of trauma, algoneurodystrophy, inflammation (osteitis) or malignant bone marrow infiltrates, such as metastases. DECT also offers means to reduce the radiation exposure of patients by replacing multiphase exams with more specific single acquisitions. The first part of this article reviews the basic principles and technical aspects of DECT. The second part focuses on applications of DECT to musculoskeletal imaging including that of gout and other crystal-induced arthropathies, virtual non-calcium images for the study of bone marrow lesions, the study of collagenous structures, as well as the detection of hemosiderin and metal particles.

Radiographic scoring methods in rheumatoid arthritis and psoriatic arthritis.

Structural changes of bone and cartilage are the hallmarks of rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Radiography can help in making diagnosis and in differentiating PsA and RA from other articular diseases. Radiography is still considered the preferred imaging method to assess disease progression, reflecting cumulative damage over time. The presence of bone erosions in RA is as an indicator of irreversible articular damage. Radiographic features of PsA are characteristic and differ from those observed in RA, especially in the distribution of affected joints and in the presence of destructive changes and bone proliferation at the same time. Semiquantitative scoring methods are designed to measure the degree of radiographically detectable joint damage and of changes over time. Several radiographic scoring methods that had been developed originally for RA have been adopted for the use in PsA. This review discusses the use of conventional radiography for diagnosing and detecting early structural changes in RA and PsA and providing a historical overview of commonly used scoring methods.