Psychological Distress in Out-Patients Assessed for Chronic Pain Compared to Those with Rheumatoid Arthritis.

Background. Patients diagnosed with chronic pain (CP) and rheumatoid arthritis (RA) represent two samples with overlapping symptoms, such as experiencing significant pain. Objectives. To compare the level of psychological distress among patients diagnosed CP attending a specialist pain clinic with those attending a specialist RA clinic. Measures. A cross-sectional study was conducted at an academic specialist chronic pain and rheumatology clinic. Participants. 330 participants included a CP group (n = 167) and a RA group (n = 163) completed a booklet of questionnaires regarding demographic characteristics, duration, and severity of their pain. Psychological and personality variables were compared between the CP and RA participants using a Multivariate Analysis of Covariance (MANCOVA). Results. Level of psychological distress based on the subscales of the DASS (depression, anxiety, and stress), PASS (escape avoidance, cognitive anxiety, fear of pain, and physiological anxiety), and PCS (rumination, magnification, and helplessness) was significantly higher in the CP group compared to the RA group. Categorization of individuals based on DASS severity resulted in significant differences in rates of depression and anxiety symptoms between groups, with a greater number of CP participants displaying more severe depressive and anxiety symptoms. Discussion and Conclusions. This study found greater levels of psychological distress among CP individuals referred to an academic pain clinic when compared to RA patients referred to an academic rheumatology clinic.

Mood, Disability, and Quality of Life among a Subgroup of Rheumatoid Arthritis Individuals with Experiential Avoidance and Anxiety Sensitivity.

Objective. The current study aimed to identify and characterize distinct RA subgroups based on their level of EA and AS and compares the difference among the subgroups in mood, disability, and quality of life. Methods. Individuals with chronic pain for at least 3 months were recruited from an academic rheumatoid clinic. Participants were assessed for demographic, psychosocial, and personality measures. A two-step cluster analysis was conducted to identify distinct subgroups of patients. Differences in clinical outcomes were compared using the Multivariate ANOVA based on cluster membership. Results. From a total of 223 participants, three distinct subgroups were formed based on cluster analysis. Cluster 1 (N = 78) included those with low levels of both EA and AS. Cluster 2 (N = 81) consisted of individuals with moderate levels of EA and low levels AS. Cluster 3 (N = 64) included those with moderate levels of EA and high AS. Compared to those in Cluster 1, those in Cluster 3 had significantly higher levels of mood impairment and disability and lower quality of life (p < 0.05). Significantly lower levels of mood impairment were seen in Cluster 1 compared to Cluster 2 (p < 0.05). However, no significant difference in disability or quality of life was seen between the two groups. Conclusions. The three subgroups differed significantly in levels of impairment in mood, disability, and quality of life. However, levels of EA had a greater impact on disability and quality of life than AS.

Outcome and survival of temporary hemodialysis catheters: a prospective study from a single center in Iraq.

BACKGROUND: The use of temporary hemodialysis catheters (THC) has facilitated the delivery of hemodialysis to patients lacking functional vascular access. However, the use of these catheters is often associated with infections or mechanical complications. METHODS: A review of experiences at a tertiary referral center in Iraq with the use of 128 THC catheters in 103 patients was undertaken over one year, to identify indications for use and outcomes and issues limiting survival. RESULTS: The indications for insertion of THC included the following: as acute dialysis access for patients with chronic renal failure (CRF) in 42.1%, failed arteriovenous fistulae in 14%, acute renal failure in 18%, failed prior THC in 18.7%, absent vascular access in patients with transplant rejection in 6.2% and severe anasarca in one patient (0.78%). The site of insertion was the right internal jugular vein in 101 patients, the right subclavian vein in 23 patients, and the left internal jugular vein in four patients. During follow-up, 86 catheters were removed: 62 in patients with end-stage renal disease (ESRD), 23 in patients with acute renal failure and one patient with severe anasarca. The reasons for removal of THC in ESRD patients were elective removal (44%), catheter related sepsis (CRS) in 30%, mechanical complications (19%) and others (7%). The subclavian site was associated with infection in 20% of patients, while the internal jugular site was associated with infection in 22.7% of patients. For patients in whom THC removal was for infection, a post removal culture of the catheter tip showed Staphylococcus aureus in 57.8%, Klebsiella in 15.7%, Pseudomonas in 15.7% and Streptococcus hemolyticus in 10.5% of the cases. CONCLUSIONS: THC is advantageous for vascular access in patients with acute renal failure. Infections and blockage significantly reduce the survival of THC in patients with ESRD. Approaches to minimize these complications are likely to lead to improved clinical outcomes with THC use.

Automated detection of lung nodules in multidetector CT: influence of different reconstruction protocols on performance of a software prototype.

PURPOSE: To evaluate the accuracy of software for computer-aided detection (CAD) of lung nodules using different reconstruction slice thickness protocols in multidetector CT. MATERIALS AND METHODS: Raw image data sets for 15 patients who had undergone 16-row multidetector CT (MDCT) for known pulmonary nodules were reconstructed at a reconstruction thickness of 5.0, 2.0 and 1.0 mm with a reconstruction increment of 1.5, 1.0 and 0.5 mm, respectively. The "Nodule Enhanced Viewing" (NEV) tool of LungCare for computer-aided detection of lung nodules was applied to the reconstructed images. The reconstructed images were also blinded and then evaluated by 2 radiologists (A and B). Data from the evaluating radiologists and CAD was then compared to an independent reference standard established using the consensus of 2 independent experienced chest radiologists. The eligible nodules were grouped according to their size (diameter > 10, 5 - 10, < 5 mm) for assessment. Statistical analysis was performed using the receiver operating characteristic (ROC) curve analysis, t-test and two-rater Cohen's Kappa co-efficient. RESULTS: A total of 103 nodules were included in the reference standard by the consensus panel. The performance of CAD was marginally lower than that of readers at a 5.0-mm reconstruction thickness (AUC = 0.522, 0.517 and 0.497 for A, B and CAD, respectively). In the case of 2.0-mm reconstruction slices, the performance of CAD was better than that of the readers (AUC = 0.524, 0.524 and 0.614 for A, B and CAD, respectively). CAD was found to be significantly superior to radiologists in the case of 1.0-mm reconstruction slices (AUC = 0.537, 0.531 and 0.675 for A, B and CAD, respectively). The sensitivity at a reconstruction thickness of 1.0 mm was determined to be 66.99 %, 68.93 % and 80.58 % for A, B and CAD, respectively. The time required for detection was shortest for CAD at reconstruction slices of 1.0 mm (mean t = 4 min). The performance of radiologists was greatly enhanced when using CAD: sensitivity 91.26 % and 94.17 % for CAD+A and CAD+B, respectively (AUC = 0.889 and 0.917). CAD was most advantageous in the detection of nodules < 10 mm. CONCLUSION: At a 1.0-mm reconstruction thickness, CAD's ability to detect nodules < 10 mm is superior to that of radiologists and its relatively short evaluation time makes it a viable second reader.

Vitamin D levels in women with systemic lupus erythematosus and fibromyalgia.

OBJECTIVE: Many patients with systemic lupus erythematosus (SLE) and fibromyalgia (FM) may spend less time exposed to the sun than healthy individuals and thus might have low vitamin D levels. It is known that hydroxychloroquine (HCQ) inhibits conversion of 25(OH)- to 1,25(OH)2-vitamin D both in vitro and in patients with sarcoidosis. We assessed winter serum 25(OH)- and 1,25(OH)2-vitamin D levels in patients with SLE and FM. METHODS: We recruited 25 consecutive female SLE and 25 female FM patients in London, Ontario, between January and March 2000. Subjects completed a brief questionnaire. Serum levels of 25(OH)-, 1,25(OH)2-vitamin D, and parathyroid hormone (PTH) were measured. RESULTS: In SLE patients mean 25(OH)-vitamin D was 46.5 nmol/l and mean 1,25(OH)2-vitamin D was 74.4 pmol/l. In FM patients these means were 51.5 nmol/l and 90.1 pmol/l, respectively. Serum 25(OH)-vitamin D levels did not significantly differ between SLE and FM patients, nor after adjusting for age and vitamin D, milk consumption, and sun block use. In 14 of the SLE patients and 12 of the FM patients 25(OH)-vitamin D levels < 50 nmol/l were found. SLE patients not using vitamin D supplements had lower 25(OH)-vitamin D levels than those who did. 1,25(OH)2-vitamin D tended to be lower in the SLE compared to the FM patients. This difference could be attributed to HCQ use: HCQ users (n = 17) had lower 1,25(OH)2-vitamin D levels than nonusers (n = 33); the mean adjusted difference was 24.4 pmol/l (95% CI 2.8-49.9). CONCLUSION: Half the SLE and FM patients had 25(OH)-vitamin D levels < 50 nmol/l, a level at which PTH stimulation occurs. Our data suggest that in SLE patients HCQ might inhibit conversion of 25(OH)-vitamin D to 1,25(OH)2-vitamin D.

Classification, epidemiology, and natural history of fibromyalgia.

Fibromyalgia (FM), also known as fibromyalgia syndrome (FMS) and fibrositis, is a common form of nonarticular rheumatism that is associated with chronic generalized musculoskeletal pain, fatigue, and a long list of other complaints. Some have criticized the classification of FM as a distinct medical entity, but existing data suggest that individuals meeting the case definition for FM are clinically somewhat distinct from those with chronic widespread pain who do not meet the full FM definition. Clinic studies have found FM to be common in countries worldwide; these include studies in specialty and general clinics. The same is true of general population studies, which show the prevalence of FM to be between 0.5% and 5%. Knowledge about risk factors for FM is limited. Females are at greater risk, and risk appears to increase through middle age, then decline. Although some authors claim that an epidemic of FM has been fueled by an over-generous Western compensation system, there are no data that demonstrate an increasing incidence or prevalence of FM; moreover, existing data refute any association between FM prevalence and compensation. Claims that the FM label itself causes illness behavior and increased dependence on the medical system also are not supported by existing research. This article reviews the classification, epidemiology, and natural history of FM.

Lumbar pannus presenting as cauda equina syndrome in a patient with longstanding rheumatoid arthritis.

Relatively little attention has been paid to lumbar spine involvement in rheumatoid arthritis (RA), and indeed it is generally considered to be an uncommon and usually clinically minor manifestation of the disease. We describe a case of acute right lower extremity weakness secondary to compression of multiple lumbar nerve roots by a large interforaminal rheumatoid pannus, and review the literature on this complication and other lumbar spine involvement in RA.

A follow-up study on occupational exposure to inhaled anaesthetics in Eastern European surgeons and circulating nurses.

OBJECTIVE: Although no dose-response relationship exists for the health risks associated with the occupational exposure to inhaled anaesthetics, public health authorities recommend threshold values. The aim of the present study was to assess whether and to what extent these threshold values are exceeded in surgeons and circulating nurses of an Eastern European university hospital, before and after measures had been taken to reduce occupational exposure. METHODS: At nine workplaces, occupational exposure to nitrous oxide and the volatile anaesthetic used (halothane or isoflurane) was measured within the breathing zones of surgeons and circulating nurses by means of photoacoustic infrared spectrometry. The measurements were carried out in 1996 and were repeated in 1997 after the installation of active scavenging devices at five workplaces, and an air-conditioning system at one workplace. RESULTS: Occupational exposure to nitrous oxide and halothane or isoflurane was lower in 1997 compared with that of 1996. In 1996, 89% of the nitrous oxide values were above the European threshold value of 100 ppm, whereas in 1997 approximately 50% were above this limit. In 1996 the majority of the measurements for the volatile anaesthetics were already below 5 ppm halothane and 10 ppm isoflurane and the number of measurements exceeding these limits was further reduced in 1997. CONCLUSION: The measures taken were effective in reducing waste gas exposure. Nevertheless, further efforts are necessary, especially for nitrous oxide, to reach Western European standards and to minimise possible health risks. These efforts comprise the installation of (active) scavenging devices, air-conditioning systems and new anaesthesia machines at all workplaces, the use of low-flow anaesthesia, the replacement of inhaled anaesthetics by intravenous anaesthetics and an appropriate working technique.

High-level, but not low-level, occupational exposure to inhaled anesthetics is associated with genotoxicity in the micronucleus assay.

UNLABELLED: To minimize the possible health risks posed by waste anesthetic gases, the National Institute of Occupational Safety and Health (NIOSH) recommends exposure limits. We investigated the genotoxicity of a previously established occupational exposure exceeding these limits (high-level exposure) and of one within these limits (low-level exposure). Genotoxicity was assessed by the formation of micronucleated lymphocytes in 25 anesthetists and anesthetic nurses of an Eastern European (High-Level Exposure Group) and a German (Low-Level Exposure Group) university hospital. Each exposed group was compared with a group of nonexposed personnel of the same hospital. Compared with its Control Group, there was an increased fraction of micronucleated lymphocytes per 1000 binucleated cells in the High-Level Exposure Group (median 14.0, range 9.0-26.7 vs median 11.3, range 3.2-19.4; P < 0.05) but not in the Low-Level Exposure Group (median 9.8, range 4.2-20.0 vs median 10.5, range 5.0-20.5). We conclude that a high-level exposure to inhaled anesthetics is associated with an increase in chromosome damage, and measures are recommended to decrease exposure levels. As evidenced by the formation of micronucleated lymphocytes, the threshold values recommended by NIOSH appear to be safe. IMPLICATIONS: A high level of occupational exposure to inhaled anesthetics is associated with genotoxicity (as defined by formation of micronucleated lymphocytes), whereas a low-level exposure (within National Institute of Occupational Safety and Health limits) is not.

A general population study of fibromyalgia tender points in noninstitutionalized adults with chronic widespread pain.

OBJECTIVE: To assess the distribution and predictive ability of fibromyalgia (FM) tender points (TP) in adults with chronic widespread pain. METHODS: Using published classification criteria, we confirmed 100 FM cases and 76 controls with widespread pain not meeting the 1990 American College of Rheumatology (ACR) classification criteria for FM (pain controls) in a survey of 3,395 adults screened for widespread musculoskeletal pain in a general population survey. RESULTS: At each of the 18 FM tender points, FM cases were more likely than pain controls to have tenderness, and the likelihood ratio (LR) was statistically greater than 1.0 for 13 of 18 points. However, the LR for individual points ranged from 4.0 to as low as 1.2. Females were more likely to have TP, especially at lower body points; however, lower body points were more discriminatory in males. CONCLUSION: TP differ in their ability to predict FM among adults in the general population with chronic widespread pain.

Occupational exposure to inhaled anaesthetics: a follow-up study on anaesthetists of an eastern European university hospital.

BACKGROUND: Although no dose-response relationship for the health risks associated with the occupational exposure to inhaled anaesthetics exists, public health authorities recommend threshold values. The aim of the present study was to assess if and to what extent these threshold values are exceeded in an eastern European university hospital before and after measures had been taken to reduce occupational exposure. METHODS: At nine workplaces occupational exposure of anaesthetists to nitrous oxide and halothane or isoflurane was measured by means of photoacoustic infrared spectrometry. The measurements were carried out in 1996 and were repeated in 1997 after the installation of active scavenging devices at five workplaces and an air-conditioning system at one workplace. RESULTS: Occupational exposure to nitrous oxide and halothane or isoflurane was lower in 1997 compared to 1996. In 1997 most of the nitrous oxide values still exceeded the threshold value of 100 ppm, whereas most of the halothane and isoflurane values were already below the threshold values of 5 ppm and 10 ppm in 1996. CONCLUSION: The measures taken were effective in reducing waste gas exposure. Nevertheless, further efforts are necessary, especially for nitrous oxide, to reach western European standards. These efforts comprise structural measures such as active scavenging devices and air-conditioning systems at all workplaces, the use of total intravenous anaesthesia, low-flow anaesthesia and an appropriate working technique.

Perspectives on posttraumatic fibromyalgia: a random survey of Canadian general practitioners, orthopedists, physiatrists, and rheumatologists.

OBJECTIVE: To determine which factors physicians consider important in patients with chronic generalized posttraumatic pain. METHODS: Using physician membership directories, random samples of 287 Canadian general practitioners, 160 orthopedists, 160 physiatrists, and 160 rheumatologists were surveyed. Each subject was mailed a case scenario describing a 45-year-old woman who sustained a whiplash injury and subsequently developed chronic, generalized pain, fatigue, sleep difficulties, and diffuse muscle tenderness. Respondents were asked whether they agreed with a diagnosis of fibromyalgia (FM), and what factors they considered to be important in the development of chronic, generalized posttraumatic pain. RESULTS: More-recent medical school graduates were more likely to agree with the FM diagnosis. Orthopedists (28.8%) were least likely to agree, while rheumatologists (83.0%) were most likely to agree. On multivariate analysis, 5 factors predicted agreement or disagreement with the diagnosis of FM: (1) number of FM cases diagnosed by the respondent per week (p < 0.0001); (2) patient's sex (p < 0.0001); (3) force of initial impact (p = 0.003); (4) patient's pre-collision psychiatric history (p = 0.03); and (5) severity of initial injuries (p = 0.03). The force of initial impact and the patient's pre-collision psychiatric history were both negatively correlated with agreement in diagnosis. Patient related factors (personality, emotional stress, pre-collision physical, mental health) were considered more important than trauma related factors in the development of chronic, widespread pain. CONCLUSION: Future studies of the association between trauma and FM should identify potential cases outside of specialty clinics, and baseline assessments should include some measurement of personality, stress, and pre-collision physical and mental health.

Co-existence of chronic fatigue syndrome with fibromyalgia syndrome in the general population. A controlled study.

OBJECTIVE: To determine the proportion of adults with fibromyalgia syndrome (FMS) in the general population who also meet the 1988 Centre for Disease Control (CDC) criteria for chronic fatigue syndrome (CFS). METHODS: Seventy-four FMS cases were compared with 32 non-FMS controls with widespread pain and 23 with localized pain, all recruited in a general population survey. RESULTS: Among females, 58.0% of fibromyalgia cases met the full criteria for CFS, compared to 26.1% and 12.5% of controls with widespread and localized pain, respectively (p=0.0006). Male percentages were 80.0, 22.2, and zero, respectively (p=0.003). Compared to those with FMS alone, those meeting the case definitions for both FMS and CFS reported a worse course, worse overall health, more dissatisfaction with health, more non-CFS symptoms, and greater disease impact. The number of total symptoms and non-CFS symptoms were the best predictors of co-morbid CFS. CONCLUSIONS: There is significant clinical overlap between CFS and FMS.

Trauma and fibromyalgia: is there an association and what does it mean?

OBJECTIVES: The primary objective is to review current research with respect to the role of trauma in fibromyalgia (FM). A secondary objective is to hypothesize which steps need to be taken, first to determine whether such an association truly exists, and second to clarify what such an association might mean. METHODS: An extensive literature review was undertaken, including Medline from 1979 to the present. RESULTS: The strongest evidence supporting an association between trauma and FM is a recently published Israeli study in which adults with neck injuries had greater than a 10-fold increased risk of developing FM within 1 year of their injury, compared with adults with lower extremity fractures (P= .001). Several other studies provide a hypothetical construct for such an association. These include studies on (1) postinjury sleep abnormalities; (2) local injury sites as a source of chronic distant regional pain; and (3) the concept of neuroplasticity. There are, however, several primary arguments against such an association: (1) FM may not be a distinct clinical entity; (2) FM may be a psychological, rather than physical, disease; (3) the evidence supporting any association is limited and not definitive; (4) the Israeli study, itself, has some methodological limitations; and (5) other factors may be more important than the injurious event in determining chronic symptoms after an acute injury. CONCLUSIONS: Although there is some evidence supporting an association between trauma and FM, the evidence is not definitive. Further prospective studies are needed to confirm this association and to identify whether trauma has a causal role.

The occurrence and impact of generalized pain.

A major problem with estimating the impact of chronic generalized pain is that the term remains undefined. It appears to encompass several distinct clinical entities, including rheumatoid arthritis and fibromyalgia, which can exist alone or together in a given individual. Nonetheless, chronic generalized pain appears to have a sizable impact on both the individual and society. Although little is known about causal relationships, demographic risk factors for chronic generalized pain are female sex, age in the forties and fifties, lower income, lower education, and being divorced or separated. Chronic generalized pain affects the individual in several ways, including physical and psychological distress, losses of function, quality of life, employment and income, and prolonged litigation for many. Its impact on society includes increased utilization of health care resources, loss of work productivity, disability and insurance costs, costs of litigation and social policy. Future research into the impact of chronic generalized pain must begin by defining this term in a way that is both valid in construct and convenient to use. Research is also warranted to develop and validate diagnostic tools that may better distinguish various subsets of chronic generalized pain, both to better understand the pathological processes involved and to allow for estimates of the relative contribution of each subset to societal costs.

Waste anaesthetic gases induce sister chromatid exchanges in lymphocytes of operating room personnel.

Genotoxicity related to waste anaesthetic gas exposure is controversial. We have investigated the frequency of sister chromatid exchanges in peripheral lymphocytes of operating room personnel exposed to trace concentrations of isoflurane and nitrous oxide. Occupational exposure was recorded using a direct reading instrument. Frequencies of sister chromatid exchanges were measured in lymphocyte cultures of 27 non-smokers working in the operating room and 27 non-smoking controls. Personnel were exposed to an 8-h time-weighted average of nitrous oxide 11.8 ppm and isoflurane 0.5 ppm. After exposure, sister chromatid exchange frequency was increased significantly (mean 9.0 (SD 1.3) vs 8.0 (1.4) in exposed and control personnel, respectively) (P < 0.05). We conclude that exposure to even trace concentrations of waste anaesthetic gases may cause genetic damage comparable with smoking 11-20 cigarettes per day.

The London Fibromyalgia Epidemiology Study: the prevalence of fibromyalgia syndrome in London, Ontario.

OBJECTIVE: To estimate the point prevalence of fibromyalgia syndrome (FM) among noninstitutionalized Canadian adults; and to assess the effect of demographic variables on the odds of having FM. METHODS: A screening questionnaire was administered via telephone to a random community sample of 3395 noninstitutionalized adults residing in London, Ontario. Individuals screening positive were invited to be examined by a rheumatologist to confirm or exclude FM using the 1990 American College of Rheumatology classification criteria. RESULTS: One hundred confirmed cases of FM were identified, of whom 86 were women. Mean age among FM cases was 49.2 years among women, 39.3 years among men (p < 0.02). FM affects an estimated 4.9% (95% CI 4.7%, 5.1%) of adult women and 1.6% (1.3%, 1.9%) of adult men in London, for a female to male ratio of roughly 3 to one. In women, prevalence rises steadily with age from < 1% in women aged 18-30 to almost 8% in women 55-64. Thereafter, it declines. The peak prevalence in men also appears to be in middle age (2.5%; 1.1%, 5.7%). FM affects 3.3% (3.2%, 3.4%) of noninstitutionalized adults in London. Female sex, middle age, less education, lower household income, being divorced, and being disabled are associated with increased odds of having FM. CONCLUSION: FM is a common musculoskeletal disorder among Canadian adults, especially among women and persons of lower socioeconomic status.