Should a Coexisting or Suspected Diagnosis of Fibromyalgia Affect the Decision to Perform Diagnostic Blocks for Patients with Chronic Noncancer Pain - Results from an Observational Research Study.

BACKGROUND: Diagnostic injections (blocks) are a valuable tool in the management of chronic noncancer pain. By precise blockade of specific neural structures and observation of pain responses, pain mechanisms can be accurately defined. With such information, therapeutic procedures targeting neural structures are possible. Fibromyalgia is a disorder of pain processing with characteristic symptoms. The 2010 American College of Rheumatologists fibromyalgia diagnostic criteria evaluates these symptoms in a scoring system, allowing more objectivity in the diagnosis. We hypothesize that patients with fibromyalgia phenotype fulfilling the 2010 American College of Rheumatologists criteria may respond to diagnostic blocks differently when compared to patients without fibromyalgia phenotype. OBJECTIVES: This study was designed to establish whether diagnosis or suspected diagnosis of fibromyalgia should influence the decision to perform diagnostic blocks for chronic non-cancer pain. STUDY DESIGN: A prospective observational research study was performed at our institution. IRAS project ID: 231514. SETTING: Tertiary pain clinic in the UK. METHODS: Patients were selected to receive diagnostic block by usual clinical assessment after which they were asked to consent to take part in the study. All participating patients completed the 2010 American College of Rheumatologists fibromyalgia diagnostic questionnaire prior to the diagnostic block. Patients were divided into 2 groups A and B based on the outcome of block - primary outcome. Group A experienced a 70% or greater improvement in pain severity following the block for the anticipated duration of action of the local anesthetic, Group B experienced a less than 70% reduction in pain. Statistical analysis between groups A and B was conducted by comparing categorical data, described as percentages, with the chi squared test. Ordinal variables such as Widespread pain index and Symptom severity score are presented as median and analyzed with Mann-Whitney test. RESULTS: Seventy-seven patients were included in the study. Two patients were lost to follow-up. Of the 75 remaining patients, 44 received lumbar medial branch blocks, 19 genicular nerve blocks, 3 blocks to nerves supplying the sacroiliac joint, one suprascapular nerve block, and 6 cervical and 2 thoracic medial branch blocks. Group A contained 38 patients and group B contained 37 patients. There was no statistically significant difference in the prevalence of fibromyalgia screening questionnaire positive patients between groups A (13 out of 38 patients) and B (13 out of 37 patients), P = 0.93. There was no statistically significant difference in the prevalence of fibromyalgia screening questionnaire positive patients in subgroups undergoing the same type of diagnostic block (spinal pain and knee pain). LIMITATIONS: Selection of patients prior to inclusion in the study may introduce bias. Patients were selected by individual treating clinicians using usual clinical practice; however, the exact selection criteria were not standardized. CONCLUSION: We conclude that after physician selection, the presence of fibromyalgia phenotype does not influence the outcome from diagnostic block. It is likely therefore that fibromyalgia phenotype should not influence the decision to perform diagnostic blocks if indicated based on assessment by an experienced pain physician.

Psychological Factors as Outcome Predictors for Spinal Cord Stimulation.

BACKGROUND AND AIMS: The mechanism of action of spinal cord stimulation (SCS) is poorly understood and the success of treatment can depend on factors beyond the technical aspects of implantation. The aim of this retrospective analysis is the identification of preimplantation psychological values that may predict outcome of SCS treatment. METHODS: The retrospective analysis consisted of data from 83 patients who underwent SCS implantation from 2005 to 2013. Preimplantation evaluation included pain severity, sleep interference and distress each recorded with a numeric rating scale (NRS 0-10), depression and anxiety (Hospital Anxiety and Depression Score-HADS), catastrophizing (Pain Catastrophizing Scale-PCS), and patient's confidence in performing daily activity (Pain Self-Efficacy Questionnaire-PSEQ). RESULTS: A fall in pain score of greater than 50% at one year follow up was the criteria applied to divide patients into two groups. Group A consisted of 39 patients whose pain score fell more than 50% and group B consisted of 44 patients whose pain score fell less than 50% at one year follow up. The median preimplantation pain score was comparable between the two groups. However, the preimplantation scores for sleep interference, HADS-depression, PCS and PSEQ, were significantly worse in group B. Receiver operating characteristic (ROC) curve analysis and univariate regression show that HADS-depression >10 and PSEQ ≤18 are risk factors for failure of SCS treatment, but only sleep interference, assessed with NRS >7 out of 10 was found to be an independent predictor of a less optimal outcome in multiple logistic regression. CONCLUSIONS: Sleep interference appears to be an independent risk factor for unsuccessful SCS therapy.

In-hospital daily insulin dose predicts long-term adverse outcome in patients with diabetes with ST-elevation myocardial infarction treated with successful primary percutaneous angioplasty.

INTRODUCTION: Early initiation of reperfusion therapy including primary percutaneous coronary revascularization (PPCI) has been recognized as a crucial factor determining clinical outcomes in the acute phase of myocardial infarction. In unstable patients with type 2 diabetes mellitus (T2D) the clear benefit from PPCI was proven. We aim to evaluate the prognostic value of factors describing glycometabolic state on admission in patients with T2D undergoing PPCI in acute ST-elevation myocardial infarction (STEMI). MATERIAL AND METHODS: Prospective analysis of clinical and laboratory variables (mean daily short acting exogenous insulin dose (DID), admission blood glucose, glycated hemoglobin (HbA1c), microalbuminuria) was performed in 112 consecutive patients with T2D with STEMI who underwent PPCI. Women comprised 58% of the group. RESULTS: Insulin dosing was targeted to obtain a mean daily glucose level < 7.8 mmol/l. During 12-month follow-up 33 (29.5%) major adverse cardiac events (major adverse cardiac events (MACE) consisting of death, reinfarction, and repeated target vessel revascularization) were reported. Microalbuminuria was present in 68 (60.5%) patients. The mean HbA1c level was 7.9%. In the multivariate logistic regression model only DID > 44 IU remained an independent risk factor for MACE (p = 0.02, OR = 5.2). CONCLUSIONS: In patients with diabetes with STEMI treated with PPCI, simple measurement of DID during hospitalization can add valuable prognostic information about the future risk of MACE.