Clinical criteria and diagnostic assessment of fibromyalgia: position statement of the Italian Society of Neurology-Neuropathic Pain Study Group

BACKGROUND

The role of central and/or peripheral nervous system dysfunction is basically fundamental in fibromyalgia.

AIM

The aim of this position statement on behalf of the Neuropathic Pain Study Group of the Italian Society of Neurology is to give practical guidelines for the clinical and instrumental assessment of fibromyalgia (FM) in the neurological clinical practice, taking into consideration recent studies.

METHODS

Criteria for study selection and consideration were original studies, case-controls design, use of standardized methodologies for clinical practice, and FM diagnosis with ACR criteria (2010, 2011, 2016).

RESULTS

ACR criteria were revised. For diagnostic procedure of small-fiber pathology, 47 studies were totally considered. Recent diagnostic criteria should be applied (ACR, 2016). A rheumatologic visit seems mandatory. The involvement of small fibers should request at least 2 among HRV + SSR and/or laser-evoked responses and/or skin biopsy and/or corneal confocal microscopy, eventually followed by monitoring of metabolic and/or immunological/ and or/paraneoplastic basis, to be repeated at 1-year follow-up.

CONCLUSIONS

The correct diagnostic approach to FM could promote the exclusion of the known causes of small-fiber impairment. The research toward common genetic factors would be useful to promote a more specific therapeutic approach.

Are maternal hemodynamic indices markers of fetal growth restriction in pregnancies with a small-for-gestational-age fetus?

OBJECTIVE

Pregnancies complicated by fetal growth restriction (FGR) have a worse outcome than those with a small-for-gestational-age (SGA) fetus. There is increasing evidence of a maternal cardiovascular role in the pathophysiology of FGR. We aimed to compare maternal hemodynamic indices between pregnancies complicated by FGR and those delivering a SGA neonate, using a non-invasive device.

METHODS

This was a prospective study of normotensive pregnancies complicated by FGR (defined as estimated fetal weight (EFW) < 3^rd centile or Doppler evidence of impaired placental-fetal blood flow), those with a SGA fetus (defined as EFW < 10^th centile) and control pregnancies with an appropriately grown fetus. Assessment of maternal hemodynamics (heart rate (HR), cardiac output (CO), mean arterial pressure (MAP), systemic vascular resistance (SVR) and stroke volume) was performed using a non-invasive device (USCOM-1A®). Uterine artery (UtA) pulsatility index (PI) was measured using transabdominal ultrasound. Hemodynamic variables that are affected by gestational age and maternal characteristics were corrected for using device-specific reference ranges. Comparison between groups was performed using the chi-square test or the Mann-Whitney U-test, as appropriate.

RESULTS

A total of 102 FGR, 64 SGA and 401 control pregnancies, with a median gestational age of 36 weeks, were included in the analysis. Women with a pregnancy complicated by FGR and those with a SGA fetus were shorter and weighed less than did controls. Compared with controls, the FGR group had significantly lower median maternal HR (80 beats per min (bpm) vs 85 bpm; P = 0.001) and CO multiples of the median (MoM; 0.91 vs 0.98; P = 0.003), and higher median maternal MAP (90 mmHg vs 87 mmHg; P = 0.040), SVR MoM (1.2 vs 1.0; P < 0.001) and UtA-PI MoM (1.1 vs 0.96; P < 0.001), but there was no significant difference in stroke volume MoM (1.0 vs 0.98; P = 0.647). Compared with the SGA group, the FGR group had a significantly lower median HR (80 bpm vs 87 bpm; P = 0.022), and higher median maternal MAP (90 mmHg vs 85 mmHg; P = 0.025), SVR MoM (1.2 vs 1.0; P = 0.002) and UtA-PI MoM (1.1 vs 0.98; P = 0.005), but there was no significant difference in CO MoM (0.91 vs 0.96; P = 0.092) or stroke volume MoM (1.0 vs 1.0; P = 0.806). There were no significant differences in adjusted maternal hemodynamic indices between the SGA group and controls.

CONCLUSION

Pregnancies complicated by FGR presented with impaired maternal hemodynamic function, as evidenced by lower HR and CO, as well as higher MAP, SVR and UtA resistance. Pregnancies delivering a SGA neonate, without evidence of FGR, had normal maternal hemodynamic function. Maternal hemodynamic indices may therefore be of value in distinguishing FGR from SGA pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Correlation between central and uterine hemodynamics in hypertensive disorders of pregnancy

OBJECTIVE

Pregnancies affected by a hypertensive disorder (HDP) have increased uterine artery pulsatility index (UtA-PI) compared with that in healthy pregnancies. Women with HDP are also known to have lower cardiac output and increased systemic vascular resistance. The aim of this study was to investigate the relationship between central and uterine hemodynamics in HDP and uncomplicated pregnancy.

METHODS

This was a prospective study of HDP and normotensive control singleton pregnancies presenting at a tertiary referral hospital between January 2012 and December 2017. Paired measurements of maternal hemodynamics, using a non-invasive device (USCOM-1A®), and UtA-PI were performed in the third trimester. HDP pregnancies were divided into preterm (onset < 37 weeks' gestation) and term (onset ≥ 37 weeks). Spearman's rank coefficient was used to assess the correlation between the central and uteroplacental hemodynamics. Regression analysis was performed to assess the association of UtA-PI with independent variables.

RESULTS

We included 231 women with HDP (152 with preterm and 79 with term HDP) and 378 controls with normotensive pregnancy. Compared with controls, women with preterm HDP had significantly lower cardiac output (median (interquartile range (IQR)), 6.0 (5.1-7.2) vs 6.6 (5.8-7.5) L/min; P < 0.001) and significantly higher systemic vascular resistance (median (IQR), 1394 (1189-1670) vs 1063 (915-1222) dynes × s/cm⁵ ; P < 0.001) and UtA-PI (median (IQR), 1.0 (0.75-1.4) vs 0.67 (0.58-0.83); P < 0.001). Conversely, in women with term HDP, there were no significant differences in heart rate, cardiac output or UtA-PI compared with controls (all P > 0.05), while systemic vascular resistance was significantly higher (median (IQR), 1315 (1099-1527) vs 1063 (915-1222) dynes × s/cm⁵ ; P < 0.001). On multiple regression analysis, heart rate, mean arterial pressure and stroke volume were associated significantly with mean UtA-PI (all P < 0.001).

CONCLUSIONS

Differences observed between HDP and normotensive pregnancies in third-trimester UtA resistance are mirrored in the central maternal hemodynamic parameters. Late pregnancy differences in the uteroplacental circulation in preterm and term HDP are an index of maternal cardiovascular function rather than being related to inadequate spiral artery remodeling and impaired placentation. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Maternal hemodynamics in normal pregnancy: reference ranges and role of maternal characteristics

OBJECTIVES

The main aim of this study was to construct reference ranges of maternal central hemodynamic parameters during pregnancy. The second aim was to determine the maternal and pregnancy characteristics that influence these hemodynamic parameters.

METHODS

This was a prospective cohort study of low-risk pregnant women attending for routine antenatal care at St George's Hospital, London, UK. Exclusion criteria included any medical disorder present at the time of study recruitment, or development of hypertension or intrauterine fetal growth restriction following study recruitment. Stroke volume (SV), cardiac output (CO) and systemic vascular resistance (SVR) were obtained using non-invasive cardiac output monitoring (USCOM-1A®). USCOM-1A utilizes a non-imaging probe in the suprasternal notch to obtain velocity-time integrals of transaortic blood flow at the left ventricular outflow tract. Once the distribution of the data with respect to gestational age had been determined, maternal characteristics were added to the model to test whether they provided a significant improvement in the prediction of the median value.

RESULTS

The study included 627 women with a singleton pregnancy. The estimated median CO was constant for a maternal age above 32 years, but was around 0.5 L/min higher for women aged ≤ 25 years (P < 0.001). Maternal weight (P < 0.001) and height (P < 0.001) significantly affected CO values and there was a significant interaction (P = 0.002) between them. In women with a height of less than 1.60 m, there was no association between median CO and weight; however, in those with a height exceeding 1.60 m, an increase in weight was associated with an increase in CO. SV was primarily associated with height (P < 0.001), although some positive association with weight (P < 0.001) could also be observed within the normal body-mass-index range. Greater height (P < 0.001) was associated with lower median values of SVR, with an estimated difference of around 120 dynes × s/cm⁵ between 1.60 m and 1.80 m. Advancing maternal age was associated with higher median SVR, with an estimated difference of around 50 dynes × s/cm⁵ between 25 and 35 years. Smokers had a lower SVR by 73.5 (95% CI, 8.6-138.4) dynes × s/cm⁵ .

CONCLUSION

Maternal hemodynamics are influenced significantly by maternal age, height and weight. We provide USCOM-1A-specific reference ranges and a calculator for SV, CO and SVR in uncomplicated pregnancies that correct for maternal age, height and weight. This should enable clinical application and comparison in both uncomplicated and pathological pregnancies. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Impaired maternal hemodynamics in morbidly obese women: a case-control study

OBJECTIVE

Maternal obesity is associated with significant pregnancy complications and is a risk factor for the development of hypertensive disorders of pregnancy as well as other adverse outcomes. There are few data regarding the hemodynamic aberrations observed in maternal obesity. The aim of this study was to investigate maternal hemodynamics in morbidly obese women.

METHODS

This was a prospective, case-control study of morbidly obese women (body mass index (BMI) ≥ 40 kg/m² ) and controls (BMI 20-29.9 kg/m² ). The control population was matched for maternal age and gestational age. BMI was calculated based on maternal height and weight at the time of recruitment to the study, which occurred on the same day as the hemodynamic assessment. Pregnant women in the second or third trimester of pregnancy were included. Women who were found to be hypertensive at any time were excluded from the study. A USCOM-1A® device was used to assess hemodynamic parameters (heart rate, stroke volume (SV), cardiac output and systemic vascular resistance (SVR)). The parameters were corrected for body surface area (BSA) to provide the SV index (SVI), cardiac index (CI) and SVR index (SVRI). Mann-Whitney U-test was used to compare the medians of the hemodynamic variables between the two groups.

RESULTS

In total, 23 morbidly obese women and 327 controls were included in the analysis. There was no difference in maternal (P = 0.506) or gestational (P = 0.693) age at recruitment between the groups. Mean arterial pressure was higher both at pregnancy booking (90 vs 80 mmHg, P < 0.001) and study recruitment (91 vs 85 mmHg, P < 0.001) in the obese group compared with the controls. Heart rate was higher in the obese group (P = 0.003), but there was no difference in SV (P = 0.271), cardiac output (P = 0.238) or SVR (P = 0.635). Following correction of these parameters for BSA, compared with the control group, SVI (34 vs 45 mL/m² , P < 0.001) and CI (2.96 vs 3.64 L/min/m² , P < 0.001) were significantly reduced in the obese group, whereas SVRI was significantly higher (2354 vs 1840 dynes × s/cm⁵ , P < 0.001).

CONCLUSIONS

The findings of our study suggest that cardiac function is significantly altered in morbidly obese pregnant women. In order to make appropriate comparisons between individuals, it is imperative that hemodynamic parameters are indexed for BSA, as is standard practice in pediatric cardiology. The novel finding of reduced CI in morbidly obese pregnant women may explain the predisposition to pre-eclampsia and other adverse outcomes in this population and warrants further investigation. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Outcome of first-trimester fetal abdominal cysts: cohort study and review of the literature

OBJECTIVES

The aims of this study were to ascertain the outcome of fetuses with an abdominal cyst detected at 11-14 weeks' gestation in our unit and to undertake a review of cases reported in the literature.

METHODS

This was a retrospective study that included all fetuses found to have an abdominal cyst on ultrasound examination at 11-14 weeks, identified over a 14-year period. Pregnancy management and outcome were ascertained from maternal and neonatal records. We also performed a review of the literature using a systematic search strategy, to identify the outcome of similar cases and propose a management algorithm.

RESULTS

Fourteen cases were identified during the study period, of which four had associated abnormalities. Of the 10 isolated cases, the cyst had resolved at follow-up scan in eight (80.0%), one fetus died in utero at 15 weeks' gestation and the other case underwent surgery for a choledochal cyst 9 weeks after birth. An additional 19 cases were reported in the literature. In eight fetuses there were associated structural abnormalities, of which four had a diagnosis of anorectal malformation after birth. In two of these four, the cyst resolved in the second trimester. Of those cases with an isolated cyst (n = 11), the cyst resolved in seven (63.6%). The remainder were variably diagnosed as hepatic cyst, ileal duplication or choledochal cyst.

CONCLUSION

Fetal abdominal cysts at 11-14 weeks' gestation are rare. They constitute an isolated finding in the majority of cases and are usually associated with a good perinatal outcome. In view of the reported association with anorectal and other gastrointestinal malformations, perinatal assessment is recommended, even if the cyst resolves during pregnancy.

Daily monitoring of biomarkers of sepsis in complicated long-term ICU-patients: can it support treatment decisions?

BACKGROUND

Diagnosis/grading of infection and the systemic response to infection may be difficult on admission to the intensive care unit, but it is even more complicated for severely ill patients with long intensive care stays. The ACCP-SCCM criteria are difficult to apply for such patients, and objective, validated biomarkers would be of great use in this setting.

METHODS

Long-term (>6 days) critically ill patients in the general ICU of University Hospital were prospectively enrolled in the study. All patients were assessed daily by the attending physician using the ACCP-SCCM classification. C-reactive protein (CRP, mg/dL), procalcitonin (PCT, ng/mL), and interleukin-6 (IL-6, pg/mL) of daily stored sera were measured after each patient's discharge. After discharge, an independent, overall clinical evaluation and an a posteriori ACCP-SCCM classification were chosen as the reference standard for all comparisons. The assessor was aware of the patient's clinical course but was blinded to levels of biomarkers.

RESULTS

We studied clinical variables and biomarkers of 26 patients over a total of 592 patient days. The day-by-day ACCP-SCCM classification of the attending physician overestimated the severity of the inflammatory response to infection. The diagnostic discriminative ability of severe-sepsis/septic-shock for PCT was high (ROC area 0.952 [0.931-0.973]) and had a best threshold value of 1.58 (83.7% sensitivity, 94.6 % specificity). IL-6 had better discriminative ability than CRP, but both were worse than PCT.

CONCLUSION

PCT > 0.43 ng/mL could add to the clinical propensity for sepsis vs. SIRS not related to infection. Values higher than 1.58 ng/mL may support the bedside clinical diagnosis of severe-sepsis. PCT between 0.5 and 1.0 suggest tight daily monitoring of clinical conditions and re-evaluation of PCT.

Description of Lyme disease-like syndrome in Brazil. Is it a new tick borne disease or Lyme disease variation?

An emerging clinical entity that reproduces clinical manifestations similar to those observed in Lyme disease (LD) has been recently under discussion in Brazil. Due to etiological and laboratory particularities it is named LD-like syndrome or LD imitator syndrome. The condition is considered to be a zoonosis transmitted by ticks of the genus Amblyomma, possibly caused by interaction of multiple fastidious microorganisms originating a protean clinical picture, including neurological, osteoarticular and erythema migrans-like lesions. When peripheral blood of patients with LD-like syndrome is viewed under a dark-field microscope, mobile uncultivable spirochete-like bacteria are observed. PCR carried out with specific or conservative primers to recognize Borrelia burgdorferi sensu stricto or the genus Borrelia has been negative in ticks and in biological samples. Two different procedures, respectively involving hematoxylin and eosin staining of cerebrospinal fluid and electron microscopy analysis of blood, have revealed spirochetes not belonging to the genera Borrelia, Leptospira or Treponema. Surprisingly, co-infection with microorganisms resembling Mycoplasma and Chlamydia was observed on one occasion by electron microscopy analysis. We discuss here the possible existence of a new tick-borne disease in Brazil imitating LD, except for a higher frequency of recurrence episodes observed along prolonged clinical follow-up.

Statin Monotherapy Attenuates Renal Injury in a Salt-Sensitive Hypertension Model of Renal Disease

BACKGROUND

Several salutary biological effects of statins have been described. We sought to investigate more closely the anti-inflammatory and antiproliferative effects of simvastatin (SIMV) in a model of hypertension and progressive renal disease, as well as its effects on the cyclin-cdk inhibitors p21 and p27.

METHODS

Munich-Wistar rats received the nitric oxide (NO) synthase inhibitor L-NAME (25 mg/kg/day p.o.) for 20 days accompanied by a high-salt diet (HS, 3% Na) and then were kept on HS for 60 days. Animals were then divided into two groups: vehicle (VH) or SIMV 2 mg/kg/day p.o. Albuminuria and tail-cuff pressure were determined at 30 and 60 days. RT-PCR was done to assess renal expression of TGF-beta1, collagen I and III, fibronectin, p27, p21 and monocyte chemoattractant protein-1 (MCP-1). Renal protein expression was assessed by Western blot (proliferating cell nuclear antigen (PCNA)) and immunostaining (macrophage, lymphocyte, PCNA).

RESULTS

SIMV did not prevent the development of severe hypertension or albuminuria. SIMV-treated animals had less severe renal interstitial inflammation and cell proliferation. MCP-1 expression was significantly diminished in the SIMV-treated animals (55.4 +/- 7.3 vs. 84.4 +/- 8.2 OD, p = 0.02). mRNA renal expression for p27 and TGF-beta did not change between groups, but p21 mRNA renal expression, highly induced in this model, significantly decreased with SIMV treatment (31.6 +/- 6.6 vs. 50.2 +/- 5.8 OD, p < 0.05). The interstitial fibrosis score significantly decreased with SIMV (2.46 +/- 0.40 vs. 4.07 +/- 0.38%, p < 0.01), which was confirmed by a decrease in renal collagen I and fibronectin expression. Serum cholesterol level did not change with SIMV.

CONCLUSION

SIMV attenuated interstitial fibrosis associated with this model of hypertensive renal disease. The mechanism involved MCP-1 downregulation. SIMV treatment was also associated with a p21 downregulation in the kidney, which might be involved in the protection of renal scarring.

In middle-aged siblings of patients with type 2 diabetes mellitus normal glucose tolerance is associated with insulin resistance and with increased insulin secretion. The SPIDER study

OBJECTIVES

To evaluate the frequency of impaired glucose tolerance (IGT) and of Type 2 diabetes mellitus (Type 2 DM) in siblings of patients with Type 2 DM, and to assess insulin release and insulin sensitivity in siblings with normal glucose tolerance (NGT), compared with NGT spouses of probands without family history of Type 2 DM.

DESIGN AND METHODS

We evaluated 87 families including 103 Type 2 DM patients (87 probands), and we carried out an oral glucose tolerance test (OGTT) in 130 siblings and in 60 spouses. Among NGT subjects, 12 siblings and 16 spouses underwent a low-dose insulin-glucose infusion test (LDIGIT) to evaluate C-peptide release and insulin sensitivity.

RESULTS

After the OGTT, 24 siblings were classified as having Type 2 DM, 31 as IGT, and only 14 spouses as IGT (P=0.0012 vs siblings). NGT siblings (n=75) showed higher insulin levels at 120 min than NGT spouses (n=46) at OGTT, in spite of identical blood glucose levels; at LDIGIT, NGT siblings secreted more C-peptide and showed a lower insulin sensitivity than NGT spouses.

CONCLUSIONS

These data indicate that middle-aged siblings of probands with Type 2 DM have a high frequency of IGT and Type 2 DM, and that NGT siblings have increased insulin resistance and increased insulin secretion when compared with adequate controls.

Recurrent eyelid basal cell carcinoma with sclerochoroidal infiltration: echographic findings

In an 82-year-old woman with a recurrent right lid basal cell carcinoma infiltrating the upper temporal orbit, a solid yellowish lesion was found ophthalmoscopically in the superotemporal periphery of the right eye. On standardized echography examination, the 2.5-mm elevated subretinal lesion was medium to high reflective with irregular structure, whereas the adjacent orbital mass was medium to low reflective and the sclera was thinned with at least one passage between the orbital and ocular lesions. To our knowledge, this is the first echographic report of sclerochoroidal infiltration from a lid basal cell carcinoma.

[Coronary atherosclerosis and sudden death in a young athlete]

A case of juvenile sudden death, occurring during athletic activity and due to obstructive atherosclerosis of coronary arteries, is reported. Repeated maximal exercise stress tests, Holter monitoring (24 hours) and echocardiograms, performed because of recurrent episodes of palpitation during effort, gave negative results. Uncertainties regarding the diagnostic sensitivity of the protocols for competitive sport fitness in revealing latent myocardial ischemia are stressed.

[Another case of juvenile sudden death caused by anomalous origin of the right coronary from the left anterior sinus of Valsalva]

A second case of sudden death during athletic activity, due to anomalous origin of the right coronary artery from the left anterior sinus of Valsalva, is presented. Post-mortem examination disclosed widespread myocardiosclerosis involving the subepicardial layers of the posterior wall of the left ventricle. Submaximal exercise testing had been performed to evaluate the presence of a ventricular extrasystole on a basal ECG, but no significant ischemic alterations of the ST tract had been detected. This case proposes once again the uncertainties regarding the diagnostic sensitivity of the protocols for competitive sport fitness in revealing latent chronic ischemia.

A native whole blood test for the evaluation of blood-surface interaction: determination of thromboxane production

The method developed to evaluate the hemocompatibility of artificial materials involves the determination of thromboxane production during the clotting of rabbit blood, in test tubes of different materials. The concentration of serum TXB2 obtained after incubation of whole blood in glass test tubes, for 40 min at 37 degrees C, averaged 416.8 +/- 23.3 ng/ml (mean +/- SE). Polymethylpentene, recognised as having a relatively poor blood compatibility, elicited 309.5 +/- 17.2 ng/ml of serum TXB2, while silicone and Avcothane, considered of better hemocompatibility, showed thromboxane levels of 276.2 +/- 28.2 and 222.9 +/- 31.5 ng/ml, respectively. These values validate the usefulness of the proposed method as a preliminary in vitro screening test of artificial materials intended for biomedical application.

EPR characterization of cellulose triacetate fibers used for enzyme immobilization

EPR studies of a nitroxide spin label and of the nitroxide spin-labeled albumin entrapped in cellulose triacetate fibers were carried out.The EPR spectra have shown that within the fiber only two phases are present: a liquid one of medium viscosity trapped inside microcavities, and a polymeric one surrounding them.After entrapment, spin-labeled albumin is distributed mainly in the liquid phase, though a not negligible amount of it remains within the polymeric matrix.The EPR studies have shown that, after the standard procedure of drying, the albumin is almost completely precipitated, but about 85% of it returns to solution when the fiber is again placed in the solution.The behavior of the albumin dissolved inside the microcavities toward denaturating agents and pH change, and that of the free albumin in solution is similar; the minor differences noticed indicate a second-order interaction between the fiber and the protein.

Infrared Combination Frequencies in Coordination Complexes containing Nitrate Groups in various Coordination Environments. A Probe for the Metal–Nitrate Interaction

The number and relative energies of nitrate combination frequencies in the 1700–1800 cm−1 region of the infrared spectrum may be used as an aid to distinguish the various coordination modes of the nitrate group. The data also provide an excellent probe for the strength of the metal–nitrate interaction.