Fibromyalgia: US Eastern Zone

Clauw DJ. · Clinical and Translational Research at University of Michigan, Ann Arbor, MI, USA. · Nat Clin Pract Rheumatol. · Pubmed #18560385 No free full text.

This publication has no abstract.

Boomershine CS, Crofford LJ. · Vanderbilt University, Nashville, TN, USA. · Nat Rev Rheumatol. · Pubmed #19337283 No free full text.

Abstract: Fibromyalgia is a prevalent disorder that is characterized by widespread pain along with numerous other symptoms, including fatigue, poor sleep, mood disorders, and stiffness. Previous guidelines for the management of fibromyalgia recommended an approach that integrates pharmacologic and nonpharmacologic therapies selected according to the symptoms experienced by individual patients. However, they offered no recommendations for a system of patient assessment that would provide a basis for individualized treatment selection. We present a simple, rapid and easily remembered system for symptom quantitation and pharmacologic management of fibromyalgia that combines visual analogue scale symptom scores from a modified form of the disease-neutral Fibromyalgia Impact Questionnaire, with a review of medications that can be used to treat the individual symptoms. This symptom-based approach is amenable to caring for patients with fibromyalgia in a busy clinical practice.

Devereaux M. · Neurological Institute, University Hospitals, Case Medical Center, Cleveland, OH 44106, USA. · Med Clin North Am. · Pubmed #19272509 No free full text.

Abstract: Neck pain is less common than low back pain but still a relatively common reason for seeing a primary care physician. Therefore, it is necessary for the primary care physician to be comfortable with salient points in the history and to be able to perform a basic neurologic examination. Important aspects of the history and physical examination are reviewed. Important clinical syndromes and treatment options are also reviewed.

Chester AC. · Department of Medicine, Georgetown University Hospital, Washington, District of Columbia, USA. · Curr Opin Otolaryngol Head Neck Surg. · Pubmed #19225306 No free full text.

Abstract: PURPOSE OF REVIEW: To summarize recent studies exploring the response of chronic rhinosinusitis (CRS) symptoms to endoscopic sinus surgery (ESS). RECENT FINDINGS: ESS symptom outcomes were reported using various symptom scoring systems and more than 18 survey instruments. When individual symptom scores were pooled by meta-analysis, most major CRS symptoms improved to a similar degree following surgery, with an overall effect size of 1.19 (95% confidence interval, 0.96-1.41; I(2) = 82%). Headache (effect size, 0.98) and hyposmia (effect size, 0.97) improved less than nasal obstruction (effect size, 1.73). Fatigue and bodily pain were more severe than general population normative values and improved following ESS by an effect size of approximately 0.5 SD, a change usually regarded as a minimally important clinical difference. Similarly, quality-of-life score in fibromyalgia improved after surgery. Neither anxiety nor depression confounded CRS symptom reporting, and neither correlated with computed tomography score; however, depression was associated with lower quality-of-life scores before and after ESS. SUMMARY: Following ESS, most major CRS symptoms usually improve to a similar degree. Bodily pain and fatigue are associated with CRS and improve after ESS. Anxiety and depression do not confound symptom reporting, although depression is associated with poorer preoperative and postoperative quality-of-life scores.

Clauw DJ. · Division of Rheumatology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA. · J Clin Psychiatry. · Pubmed #19200425 No free full text.

Abstract: Fibromyalgia is a common and disabling condition that may be difficult to assess and diagnose owing to its wide range of symptoms and common comorbidities. The most common symptoms of fibromyalgia include widespread pain over the whole body, pain at specific tender points, fatigue, memory and other cognitive problems, sleep and mood disturbances, and impaired functioning. Accurately diagnosing fibromyalgia may require diagnostic testing and physical examinations such as tender points examinations; however, patients with longstanding symptoms may be diagnosed according to a symptom-based fibromyalgia criteria checklist. This activity provides a sample assessment and diagnosis in a clinical situation.

Burstein SH, Zurier RB. · Department of Biochemistry & Molecular Pharmacology, University of Massachusetts Medical School, 364 Plantation St., Worcester, Massachusetts 01605, USA. · AAPS J. · Pubmed #19199042 No free full text.

Abstract: This review covers reports published in the last 5 years on the anti-inflammatory activities of all classes of cannabinoids, including phytocannabinoids such as tetrahydrocannabinol and cannabidiol, synthetic analogs such as ajulemic acid and nabilone, the endogenous cannabinoids anandamide and related compounds, namely, the elmiric acids, and finally, noncannabinoid components of Cannabis that show anti-inflammatory action. It is intended to be an update on the topic of the involvement of cannabinoids in the process of inflammation. A possible mechanism for these actions is suggested involving increased production of eicosanoids that promote the resolution of inflammation. This differentiates these cannabinoids from cyclooxygenase-2 inhibitors that suppress the synthesis of eicosanoids that promote the induction of the inflammatory process.

Arnold LM, Bradley LA, Clauw DJ, Glass JM, Goldenberg DL. · Women's Health Research Program, Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA. · J Clin Psychiatry. · Pubmed #19192431 No free full text.

Abstract: Fibromyalgia is a common and disabling chronic pain syndrome that is often accompanied by other chronic pain and/or psychiatric comorbidities, which impact fibromyalgia course and outcome. Although a primary care provider will likely take the lead in caring for patients with fibromyalgia, psychiatrists and other mental health professionals may play a role in the diagnosis, evaluation, and management of fibromyalgia. Psychiatrists' familiarity with many of the pharmacologic and nonpharmacologic treatments that are currently being used for fibromyalgia make them valuable partners in the multidisciplinary team of clinicians addressing fibromyalgia and its comorbidities. In this activity, experts on fibromyalgia discuss the nature of the syndrome and its diagnosis and evaluation.

Schneider M, Vernon H, Ko G, Lawson G, Perera J. · School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pa, USA. · J Manipulative Physiol Ther. · Pubmed #19121462 No free full text.

Abstract: OBJECTIVE: Fibromyalgia syndrome (FMS) is one of the most commonly diagnosed nonarticular soft tissue conditions in all fields of musculoskeletal medicine, including chiropractic. The purpose of this study was to perform a comprehensive review of the literature for the most commonly used treatment procedures in chiropractic for FMS and to provide evidence ratings for these procedures. The emphasis of this literature review was on conservative and nonpharmaceutical therapies. METHODS: The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. Online comprehensive literature searches were performed of the following databases: Cochrane Database of Systematic Reviews; National Guidelines Clearinghouse; Cochrane Central Register of Controlled Trials; Manual, Alternative, and Natural Therapy Index System; Index to Chiropractic Literature, Cumulative Index to Nursing and Allied Health Literature; Allied and Complementary Medicine; and PubMed up to June 2006. RESULTS: Our search yielded the following results: 8 systematic reviews, 3 meta-analyses, 5 published guidelines, and 1 consensus document. Our direct search of the databases for additional randomized trials did not find any chiropractic randomized clinical trials that were not already included in one or more of the systematic reviews/guidelines. The review of the Manual, Alternative, and Natural Therapy Index System and Index to Chiropractic Literature databases yielded an additional 38 articles regarding various nonpharmacologic therapies such as chiropractic, acupuncture, nutritional/herbal supplements, massage, etc. Review of these articles resulted in the following recommendations regarding nonpharmaceutical treatments of FMS. Strong evidence supports aerobic exercise and cognitive behavioral therapy. Moderate evidence supports massage, muscle strength training, acupuncture, and spa therapy (balneotherapy). Limited evidence supports spinal manipulation, movement/body awareness, vitamins, herbs, and dietary modification. CONCLUSIONS: Several nonpharmacologic treatments and manual-type therapies have acceptable evidentiary support in the treatment of FMS.

McPartland JM. · Department of Osteopathic Manipulative Medicine, Michigan State University, East Lansing, MI, USA. · J Bodyw Mov Ther. · Pubmed #19083670 No free full text.

Abstract: The endocannabinoid (eCB) system, like the better-known endorphin system, consists of cell membrane receptors, endogenous ligands and ligand-metabolizing enzymes. Two cannabinoid receptors are known: CB(1) is principally located in the nervous system, whereas CB(2) is primarily associated with the immune system. Two eCB ligands, anandamide (AEA) and 2-arachidonoylglycerol (2-AG), are mimicked by cannabis plant compounds. The first purpose of this paper was to review the eCB system in detail, highlighting aspects of interest to bodyworkers, especially eCB modulation of pain and inflammation. Evidence suggests the eCB system may help resolve myofascial trigger points and relieve symptoms of fibromyalgia. However, expression of the eCB system in myofascial tissues has not been established. The second purpose of this paper was to investigate the eCB system in fibroblasts and other fascia-related cells. The investigation used a bioinformatics approach, obtaining microarray data via the GEO database (www.ncbi.nlm.nih.gov/geo/). GEO data mining revealed that fibroblasts, myofibroblasts, chondrocytes and synoviocytes expressed CB(1), CB(2) and eCB ligand-metabolizing enzymes. Fibroblast CB(1) levels nearly equalled levels expressed by adipocytes. CB(1) levels upregulated after exposure to inflammatory cytokines and equiaxial stretching of fibroblasts. The eCB system affects fibroblast remodeling through lipid rafts associated with focal adhesions and dampens cartilage destruction by decreasing fibroblast-secreted metalloproteinase enzymes. In conclusion, the eCB system helps shape biodynamic embryological development, diminishes nociception and pain, reduces inflammation in myofascial tissues and plays a role in fascial reorganization. Practitioners wield several tools that upregulate eCB activity, including myofascial manipulation, diet and lifestyle modifications, and pharmaceutical approaches.

Melvin CL, Carey TS, Goodman F, Oldham JM, Williams JW, Ranney LM. · The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, NC 27599-7590, USA. · J Psychiatr Pract. · Pubmed #19034205 No free full text.

Abstract: Bipolar disorder is characterized by chronic and recurrent symptoms including mania, hypomania, and depressive and mixed episodes, with approximately 5.7 million Americans over age 18, or 2.6% of the U.S. population, suffering from the illness. The prevalence of the disorder may be higher due to its chronic and recurrent nature. Individuals with bipolar disorder often first present in general medical settings with depressive symptomatology. Long-term management typically occurs in mental health settings by psychiatrists or other mental health specialists. While there have been major advances in pharmacotherapy for bipolar disorder, evidence-based information on drug effectiveness is not always easily accessible to prescribers in daily practice. Available information has sometimes led to inappropriate use of various classes of drugs, specifically antiepileptic drugs (AEDs), for bipolar disorder. Originally approved in 1993 by the U.S. Food and Drug Administration (FDA) only for adjunctive treatment of partial complex seizures, the manufacturer of gabapentin (Neurontin), an AED, promoted its off-label use for treatment of psychiatric disorders, including bipolar disorder. The efficacy of the drug for this indication had not been demonstrated, nor had the manufacturer sought FDA approval for the indication. In 2004, 50 Attorneys General settled consumer protection claims regarding alleged deceptive off-label marketing practices of Pfizer subsidiary Warner-Lambert. At about the same time, a consortium of State Medicaid agencies funded a drug class review to compare effectiveness and adverse event profiles of AEDs in the treatment of bipolar mood disorder, neuropathic pain, and fibromyalgia. This article presents a summary of the findings from the drug class review related to prescription of the AEDs in bipolar disorder.

Staud R. · Department of Medicine, University of Florida College of Medicine, PO Box 100221, D2-39, Gainesville, FL 32610, USA. · Curr Rheumatol Rep. · Pubmed #19007537 No free full text.

Abstract: Although fibromyalgia (FM) syndrome is defined by chronic widespread pain and tenderness, additional symptoms, including disabling fatigue and dizziness, are often reported by patients with this chronic illness. Although nonrestorative sleep may play an important role for chronic fatigue in FM, other mechanisms, including dysfunction of the autonomic nervous system (ANS), need to be considered. Many important biological functions, such as heart rate, blood pressure, respirations, and bowel function, are tightly regulated by the ANS. However, dysfunction of the ANS is common in FM and often becomes quite apparent after positional changes from supine to upright. Although such positional changes sometimes result in syncope, they are more often associated with palpitations and dizziness. Head-up tilt table testing can be used to evaluate autonomic dysfunction and is frequently helpful for the work-up of FM complaints, including fatigue, dizziness, and palpitations. One of the most common events experienced by FM patients during tilt table testing is postural orthostatic tachycardia syndrome, which is defined as a heart rate increase of more than 30 beats per minute after more than 3 minutes of standing upright.

Krymchantowski AV, Bryson J, Lipton RB, Bigal ME. · Merck Research Laboratories, 1 Merck Drive, Whitehouse Station, NJ 08889, USA. · Curr Pain Headache Rep. · Pubmed #18765137 No free full text.

Abstract: Migraine and fibromyalgia are prevalent and disabling disorders with few preventive medications approved by the US Food and Drug Administration (FDA). Neuromodulators (or antiepileptic drugs; AEDs) are often effective in the treatment of these conditions. Divalproex sodium and topiramate are FDA-approved AEDs for migraine. For fibromyalgia, pregabalin has recently been approved in the United States. We review the use of AEDs in the preventive treatment of these highly prevalent disorders.

See S, Ginzburg R. · St. John's University College of Pharmacy and Allied Health Professions, Jamaica, New York 11439, USA. · Am Fam Physician. · Pubmed #18711953 No free full text.

Abstract: Skeletal muscle relaxants are widely used in treating musculoskeletal conditions. However, evidence of their effectiveness consists mainly of studies with poor methodologic design. In addition, these drugs have not been proven to be superior to acetaminophen or nonsteroidal anti-inflammatory drugs for low back pain. Systematic reviews and meta-analyses support using skeletal muscle relaxants for short-term relief of acute low back pain when nonsteroidal anti-inflammatory drugs or acetaminophen are not effective or tolerated. Comparison studies have not shown one skeletal muscle relaxant to be superior to another. Cyclobenzaprine is the most heavily studied and has been shown to be effective for various musculoskeletal conditions. The sedative properties of tizanidine and cyclobenzaprine may benefit patients with insomnia caused by severe muscle spasms. Methocarbamol and metaxalone are less sedating, although effectiveness evidence is limited. Adverse effects, particularly dizziness and drowsiness, are consistently reported with all skeletal muscle relaxants. The potential adverse effects should be communicated clearly to the patient. Because of limited comparable effectiveness data, choice of agent should be based on side-effect profile, patient preference, abuse potential, and possible drug interactions.

Small E. · Department of Pediatrics, Mount Sinai School of Medicine, 666 Lexington Avenue, Mount Kisco, NY 10549, USA. · Adolesc Med State Art Rev. · Pubmed #18605399 No free full text.

Abstract: Reflex sympathetic dystrophy is defined as chronic musculoskeletal pain and autonomic dysfunction. It is a difficult diagnosis to make, and the adolescent often sees many specialists before arriving at the correct diagnosis. In this article I review reflex sympathetic dystrophy and reflect on the differential diagnosis, pertinent medical history, personal characteristics of patients with reflex sympathetic dystrophy, physical examination, and laboratory evaluation. Principles of management are considered, including physical therapy, pharmacology, psychological therapy, and alternative therapies. Accurate diagnosis and management are critical for not prolonging the adolescent's and the family's suffering. It is important to provide aggressive physical therapy, stress management, relaxation training, and close follow-up. It is also critical to avoid immobilization, surgery, or invasive procedures and unnecessary tests.

Navari RM. · Indiana University School of Medicine, South Bend, 100 Raclin-Carmichael Hall, South Bend, IN 46617, USA. · Curr Opin Investig Drugs. · Pubmed #18600583 No free full text.

Abstract: Casopitant, an inhibitor of the neurokinin-1 receptor, and its mesylate salt, are being developed by GlaxoSmithKline plc for the potential treatment of chemotherapy-induced nausea and vomiting (CINV), post-operative nausea and vomiting (PONV), as well as for anxiety, depression and insomnia. Phase II trials are ongoing for anxiety, depression and insomnia, and further results are awaited from phase III trials of CINV and PONV. At the time of publication, it was expected that applications to the FDA for regulatory approval for CINV and PONV would be filed in 2008. Casopitant was previously being developed for the treatment of overactive bladder; however, in September 2007, this indication was no longer listed on the company's product pipeline.

Abeles M, Solitar BM, Pillinger MH, Abeles AM. · Division of Rheumatology, Department of Medicine, The University of Connecticut School of Medicine, Farmington, USA. · Am J Med. · Pubmed #18589048 No free full text.

Abstract: Primary fibromyalgia, a poorly-understood chronic pain syndrome, is characterized by widespread musculoskeletal pain, nonrestorative sleep, fatigue, psychological distress, and specific regions of localized tenderness, all in the absence of otherwise apparent organic disease. While the etiology of fibromyalgia is unclear, accumulating data suggest that disordered central pain processing likely plays a role in the pathogenesis of symptoms. Although various pharmacological treatments have been studied and espoused for treating fibromyalgia, no single drug or group of drugs has proved to be particularly useful in treating fibromyalgia patients as a whole, and only one drug to date has earned U.S. Food and Drug Administration approval for treating the syndrome in the United States. This review critically and systematically evaluates clinical investigations of medicinal and nonmedicinal treatments for fibromyalgia dating from 1970 to 2007.

Clauw DJ. · Division of Rheumatology, Department of Internal Medicine, and Michigan Institute for Clinical and Health Research, University of Michigan Medical School, Ann Arbor, USA. · J Clin Psychiatry. · Pubmed #18537460 No free full text.

Abstract: Fibromyalgia is a common and disabling syndrome. Despite research detailing the efficacy of a variety of medicinal treatments, most notably, tricyclic antidepressants, serotonin-norepinephrine re-uptake inhibitors, and alpha(2)delta ligands, there is still widespread, routine use of agents that are mostly ineffective in treating the central nature of fibromyalgic pain. This article discusses pharmacotherapeutic options for fibromyalgia, including those with high-level evidence for efficacy, moderate-level evidence, and little or no evidence for efficacy. The importance of an integrated treatment approach that includes pharmacotherapy and at least one, but preferably more, of the most effective nonmedicinal treatment options available (e.g., education, aerobic exercise, and cognitive-behavioral therapy) is also discussed.

Glass JM. · Substance Abuse Section, Department of Psychiatry, University of Michigan Medical School, Ann Arbor, USA. · J Clin Psychiatry. · Pubmed #18537459 No free full text.

Abstract: Patients with fibromyalgia frequently complain of cognitive problems or "fibrofog." The existence of these symptoms has been confirmed by studies of the incidence of cognitive problems in fibromyalgia patients and by the results of objective tests of metamemory, working memory, semantic memory, everyday attention, task switching, and selective attention. The results of these tests show that fibromyalgia patients have impairments in working, episodic, and semantic memory that mimic about 20 years of aging. These patients have particular difficulty with memory when tasks are complex and their attention is divided. Cognitive symptoms in these patients may be exacerbated by the presence of depression, anxiety, sleep problems, endocrine disturbances, and pain, but the relationship of these factors to cognitive problems in fibromyalgia patients is unclear. Standardized tests and treatment have not yet been established for cognitive problems in fibromyalgia patients.

Arnold LM. · Division of Women's Health Research Program, Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA. · J Clin Psychiatry. · Pubmed #18537458 No free full text.

Abstract: According to the American College of Rheumatology, fibromyalgia is widespread pain of at least 3 months' duration in combination with pain at 11 or more of 18 specific tender point sites on the body. Many individuals with fibromyalgia also have comorbid psychiatric disorders, which can present diagnostic dilemmas and require additional treatment considerations to optimize patient outcomes. Fibromyalgia has been found to be strongly associated with depressive and anxiety symptoms, a personal or family history of depression, and accompanying antidepressant treatment. Psychiatric comorbidities negatively impact the severity and course of fibromyalgia. Pharmacotherapy can be employed to control fibromyalgia and comorbid mood and anxiety disorders. Additionally, nonpharmacologic therapies for fibromyalgia and comorbid psychiatric disorders include cognitive-behavioral therapy and aerobic exercise. The efficacy of pharmacologic and nonpharmacologic treatments is examined in this article, as well as the diagnostic difficulties that comorbid disorders present.

Jacobson TA. · Office of Health Promotion and Disease Prevention, Emory University, Faculty Office Building, 49 Jessie Hill Jr Dr SE, Atlanta, GA 30303, USA. · Mayo Clin Proc. · Pubmed #18533086 links to  free full text

Abstract: Myalgia, which often manifests as pain or soreness in skeletal muscles, is among the most salient adverse events associated with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins). Clinical issues related to statin-associated myotoxicity include (1) incidence in randomized controlled trials and occurrence in postmarketing surveillance databases; (2) potential differences between statins in their associations with such adverse events; and (3) diagnostic and treatment strategies to prevent, recognize, and manage these events. Data from systematic reviews, meta-analyses, clinical and observational trials, and post-marketing surveillance indicate that statin-associated myalgia typically affects approximately 5.0% of patients, as myopathy in 0.1% and as rhabdomyolysis in 0.01%. However, studies also suggest that myalgia is among the leading reasons patients discontinue statins (particularly high-dose statin monotherapy) and that treatment with certain statins (eg, fluvastatin) is unlikely to result in such adverse events. This review presents a clinical algorithm for monitoring and managing statin-associated myotoxicity. The algorithm highlights risk factors for muscle toxicity and provides recommendations for (1) creatine kinase measurements and monitoring; (2) statin dosage reduction, discontinuation, and rechallenge; and (3) treatment alternatives, such as extended-release fluvastatin with or without ezetimibe, low-dose or alternate-day rosuvastatin, or ezetimibe with or without colesevelam. The algorithm should help to inform and enhance patient care and reduce the risk of myalgia and other potentially treatment-limiting muscle effects that might undermine patient adherence and compromise the overall cardioprotective benefits of statins.

Crofford LJ. · University of Kentucky, Lexington, Kentucky 40536, USA. · Curr Opin Rheumatol. · Pubmed #18388513 No free full text.

Abstract: PURPOSE OF REVIEW: Pain is the primary presenting symptom in the vast majority of inflammatory and noninflammatory rheumatic diseases. Patients tell us that improved pain relief is a principal concern. Many pain complaints respond incompletely to the treatment of the primary rheumatic disorder and pain syndromes such as fibromyalgia do not respond to traditional analgesic medications. Therefore, proper management requires consideration of additional medications for symptomatic relief. This review addresses newer strategies for the treatment of pain in patients with fibromyalgia that may be also useful in patients with other rheumatic diseases. RECENT FINDINGS: New medications have been developed with a better understanding of chronic pain mechanisms that principally address pain neurobiology at the levels of the spinal cord and the brain. Clinical studies demonstrate the effectiveness of the alpha-2-delta ligands (gabapentin and pregabalin) and the norepinephrine/serotonin reuptake inhibitors (duloxetine and milnacipran) in fibromyalgia. SUMMARY: Patients with chronic pain, best classified as fibromyalgia, either primary or in association with other rheumatic disorders, may experience benefit from new therapies targeting central pain mechanisms.

Rooks DS. · Division of Rheumatology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA. · Curr Opin Rheumatol. · Pubmed #18349753 No free full text.

Abstract: PURPOSE OF REVIEW: The purpose of this article is to describe the application of basic exercise principles to individuals with fibromyalgia to encourage clinicians to discuss with their patients ways of becoming more physically active. RECENT FINDINGS: The goals of increased physical activity and exercise for individuals with fibromyalgia are to improve or maintain general fitness, physical function, emotional well being, symptoms and overall health, and provide them with a feeling of control over their well being. Describing ways of increasing activity through home, work and leisure-related tasks or exercise provides a universal approach to increasing physical activity that applies to individuals with fibromyalgia and fits a counseling model of health behavior familiar to clinicians. The patient-clinician relationship provides a unique opportunity for health professionals to counsel individuals with fibromyalgia to become and remain more physically active. SUMMARY: Regular physical activity and exercise has numerous physical, psychological, and functional benefits for individuals with fibromyalgia and should be included in treatment plans. Clinicians can help patients adopt a more physically active lifestyle through targeted discussions, support and consistent follow up.

Mazer M, Perrone J. · Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. · J Med Toxicol. · Pubmed #18338302 No free full text.

Abstract: Acetaminophen-induced liver necrosis has been studied extensively, but the extrahepatic manifestations of acetaminophen toxicity are currently not described well in the literature. Renal insufficiency occurs in approximately 1-2% of patients with acetaminophen overdose. The pathophysiology of renal toxicity in acetaminophen poisoning has been attributed to cytochrome P-450 mixed function oxidase isoenzymes present in the kidney, although other mechanisms have been elucidated, including the role of prostaglandin synthetase and N-deacetylase enzymes. Paradoxically, glutathione is considered an important element in the detoxification of acetaminophen and its metabolites; however, its conjugates have been implicated in the formation of nephrotoxic compounds. Acetaminophen-induced renal failure becomes evident after hepatotoxicity in most cases, but can be differentiated from the hepatorenal syndrome, which may complicate fulminant hepatic failure. The role of N-acetylcysteine therapy in the setting of acetaminophen-induced renal failure is unclear. This review will focus on the pathophysiology, clinical features, and management of renal insufficiency in the setting of acute acetaminophen toxicity. CASE: A 47-year-old female was found lethargic at home and brought by ambulance to an emergency department. History from family members suggested an inadvertent acetaminophen overdose, and she had last been seen a few hours earlier. She reportedly ingested 18 tablets of 500 mg acetaminophen (APAP) over the previous two days because she had run out of her prescription pain medication. Her past medical history was significant for fibromyalgia, arthritis, and a prior gastric bypass procedure. She had no history of alcohol abuse or renal insufficiency. She was lethargic. Vital signs: BP 128/96 mmHg, pulse 112/min, respirations 32/min; pulse oximetry 98% on 2L nasal cannula oxygen. Laboratory studies: BUN 9 mg/dL, creatinine 0.9 mg/dl, acetaminophen 12 mcg/mL, AST 5409 u/L and ALT 1085 u/L. A urinalysis was negative for blood with trace protein and ketones. A urine drug screen was positive for marijuana and opioid metabolites. At the initial hospital, she was treated with N-acetylcysteine (NAC) orally. Subsequently, she developed fulminant hepatic failure with elevated transaminases, hypoglycemia, and coagulopathy (Tables 1A and 1B). She was transferred to our facility two days after initial presentation for liver transplant evaluation. At that time, her APAP level was 2.0 mg/L. Oral NAC therapy was continued after transfer. The patient's liver function subsequently improved and she ultimately did not require transplantation. She did develop acute renal failure during the course of her hospitalization, with a creatinine of 2.3 mg/dL on transfer, which increased to 8.1 mg/dL nine days later (approximately 11-13 days post-ingestion). Medical toxicology was consulted by the intensive care unit team to address whether this was acetaminophen-induced renal failure and if there was a role for NAC in this setting.

Staud R, Spaeth M. · Division of Rheumatology and Clinical Immunology, McKnight Brain Institute, University of Florida, Gainesville, FL 32610-0221, USA. · CNS Spectr. · Pubmed #18323768 links to  free full text

Abstract: Fibromyalgia pain is frequent in the general population, but its pathogenesis is only partially understood. Patients with fibromyalgia lack consistent tissue abnormalities but display features of hyperalgesia (increased sensitivity to painful stimuli) and allodynia (lowered pain threshold). Many recent fibromyalgia studies have demonstrated central nervous system (CNS) pain processing abnormalities, including abnormal temporal summation of pain. In the CNS, persistent nociceptive input from peripheral tissues can lead to neuroplastic changes resulting in central sensitization and pain. This mechanism appears to represent a hallmark of fibromyalgia and many other chronic pain syndromes, including irritable bowel syndrome, temporomandibular disorder, migraine, and low back pain. Importantly, after central sensitization has been established, only minimal peripheral input is required for the maintenance of the chronic pain state. Additional factors, including pain-related negative affect and poor sleep have been shown to significantly contribute to clinical fibromyalgia pain. Better understanding of these mechanisms and their relationship to central sensitization and clinical pain will provide new approaches for the prevention and treatment of fibromyalgia and other chronic pain syndromes.

Staud R. · University of Florida, PO Box 100221, D2-39, Gainesville, FL 32610-0221, USA. · Curr Rheumatol Rep. · Pubmed #18177601 No free full text.

Abstract: Acupuncture (AP) is effective for the treatment of postoperative and chemotherapy-induced nausea/vomiting and for postoperative dental pain. Several recent randomized trials have provided strong evidence for beneficial AP effects on chronic low-back pain and pain from knee osteoarthritis. For many other chronic pain conditions, including headaches, neck pain, and fibromyalgia, the evidence supporting AP's efficacy is less convincing. AP's effects on experimental pain appear to be mediated by analgesic brain mechanisms through the release of neurohumoral factors, some of which can be inhibited by the opioid antagonist naloxone. In contrast to placebo analgesia, AP-related pain relief takes considerable time to develop and to resolve. Thus, some of the long-term effects of AP analgesia cannot be explained by placebo mechanisms. Furthermore, it appears that some forms of AP are more effective for providing analgesia than others. Particularly, electro-AP seems best to activate powerful opioid and non-opioid analgesic mechanisms.