Reliability of ACR criteria over time to differentiate classic fibromyalgia from nonspecific widespread pain syndrome: a 6-month prospective cohort study

American College of Rheumatology (ACR) 1990 criteria, initially introduced to classify fibromyalgia (FM) syndrome, has gained popularity in research and clinical grounds for diagnostic purposes. The objectives of this study were designed to assess the consistency of ACR criteria against the time in classifying FM. This was a prospective cohort study performed in a multidisciplinary pain clinic from October 2002 to June 2005. Patients who were clinically suspected of having FM and had a normal screening laboratory evaluation were scheduled for dolorimetry. Those found to have 6 or more tender points were considered eligible and labeled as either classic or atypical FM if they did or did not, respectively, fulfil ACR criteria. The 2 groups were assessed using the Fibromyalgia Impact Questionnaire (FIQ) and compared using baseline characteristics. We reassessed dolorimetric exam and FIQ 6 months later. Of 91 patients who participated in this study, 70 completed the follow-up. Of them, 34 (49%) patients were identified as atypical, and 36 (51%) were labeled as classic FM. At first visit, the classic FM group had higher scores on sleep quality, stiffness, anxiety, depression, and total FIQ score (p < 0.05) but not for other variables. At 6 months, there was no significant difference between the 2 groups in all measured variables. Labeling shift from classic to atypical FM and vice versa occurred at a rate of 36.1 and 32.4%, respectively. This study showed the ACR 1990 criteria was not able to consistently classify affected patients with FM syndrome within a group of patients having nonspecific body pain and multiple tender points over 6 months of follow-up.     

Incidence and risk factors for infantile colic in Iranian infants

AIM： To assess the incidence of infantile colic and its association with variable predictors in infants born in a community maternity hospital, Tehran, Iran. METHODS： In this prospective cohort study, mothers who gave birth to live newborns between February 21 and March 20, 2003 at the hospital were invited to join to the study. For every infant-mother dyad data were collected on infant gender, type of delivery, gestational age at birth, birth weight, birth order, and mother＇s reproductive history. Then mothers were given a diary to document the duration of crying/fussiness behav-iors of their infants for the next 12 wk. We scheduled home visits at the time the infants were 3 mo of age to collect the completed diaries and obtain additional information on infants＇ nutritional sources and identify if medications were used for colic relief. Cases of colic were identifi ed by applying Wessel criteria to recorded data. Chi-square and Mann-whitney U tests were used to compare proportions for non-parametric and para-metric variables, respectively. RESULTS： From 413 infants, follow-up was completed for 321 infants. In total, 65 infants （20.24%） satisfi ed the Wessel criteria for infantile colic. No statistical sig-nifi cance was found between colicky and non-colicky infants according to gender, gestational age at birth, birth weight, type of delivery, and, infant＇s feeding pattern. However, fi rstborn infants had higher rate for developing colic （P = 0.03）. CONCLUSION： Colic incidence was 20% in this popu-lation of Iranian infants. Except for birth order status, no other variable was signifi cantly associated with in-fantile colic.     

Brucellar meningitis in an infant--evidence for human breast milk transmission

Brucellar meningitis is relatively uncommon, especially in children younger than 1 year. We present another case of meningitis due to Brucella melitensis biotype 1 in a 11-month-old infant transmitted by breast milk. This is the first report of successful isolation of B. melitensis from the breast milk in the literature. Babies of infected nursing mother should be monitored closely for evidence of infection since the breast milk is the source of transmission of brucellosis. It would be prudent to abstain from breast feeding until infection of nursing mother has been eradicated. One should be aware of this in endemic areas.     

蝶窦外侧壁的显微解剖及其在扩大经蝶手术中的应用

背景与目的：经蝶入路的手术范围已经从鞍区扩展到海绵窦、颅中窝等处。本研究对蝶窦气化延伸及其与周围神经血管关系的解剖进行观测,旨在为扩大经蝶手术的术前评估提供参考,避免术中重要结构的损伤。方法：结合尸头解剖与头颅CT,对蝶窦外侧壁的气化方向的变异及其与邻近神经血管结构的关系进行观察、描述和分析。结果：当蝶窦气化向外侧方向扩展超过连接圆孔颅外端内侧缘与翼管前端开口内侧缘的VR线（Vidian-Rotundum line）时,该蝶窦被称为外侧型蝶窦。VR线外侧的蝶窦部分称为蝶窦外侧隐窝。外侧型蝶窦可分为蝶骨大翼型、翼突型和全外侧型。本研究在100例CT扫描中,外侧型蝶窦占46%。其中蝶骨大翼型占12%,翼突型占11%,全外侧型占71%。结论：外侧型蝶窦中的外侧隐窝可为经蝶窦和经上颌窦入路切除海绵窦区和颅中窝病灶提供自然手术通道。     

Validation of the 2010 American College of Rheumatology preliminary diagnostic criteria for fibromyalgia in an Iranian population

The aim of this study was to validate the 2010 American College of Rheumatology (ACR) preliminary criteria for fibromyalgia (FM) in an Iranian population. In this multicenter prospective study, we enrolled 168 FM patients and 110 controls. All participants underwent dolorimetry examination by study assessors and completed a questionnaire containing variables of both the ACR 2010 preliminary and ACR 1990 criteria. We compared the performance of the ACR 2010 criteria with the expert diagnosis as well as the ACR 1990 criteria. Receiver operator characteristic analyses and Youden index were used to evaluate the test characteristics of a set of different cutoff points for two subcomponents of ACR 2010 criteria including widespread pain index (WPI) and symptom severity (SS) scale. Considering expert diagnosis as the gold standard, the ACR 2010 criteria showed comparable specificity with ACR 1990 (92.8 vs. 88.3 %, P = 0.073), but lower sensitivity (58.9 vs. 71.4 %, P = 0.003) and a tendency for lower accuracy (72.4 vs. 78.4 %, P = 0.105). Applying the ACR 1990 criteria as the gold standard, we observed a trend toward an increase in overall accuracy (72.4 vs. 79.1 %, P = 0.064). Optimal test characteristics were achieved for WPI ≥6 and SS scale score ≥4 and improved sensitivity and accuracy of ACR 2010 criteria when compared to expert, 76.1 and 81.7, respectively. The preliminary ACR 2010 criteria performed less desirably in terms of sensitivity in our set of Iranian patients. Selecting lower cutoff points as WPI ≥6 and SS scale score ≥4 improved the diagnostic values of the criteria.     

Spontaneous intracranial hypotension: dilemmas in diagnosis

Intracranial hypotension is not an uncommon diagnosis after lumbar puncture or neurosurgery. However, spontaneous intracranial hypotension (SIH) is a poorly understood entity that can present with a wide variety of symptoms/signs ranging from headache to coma. SIH may result from an occult spinal cerebrospinal fluid (CSF) leak. Alternatively, because a CSF leak is not always found, some posit that SIH is caused by venous hypotension that results in increased CSF absorption. The true incidence of SIH is unknown and the diagnosis is frequently missed given the wide range of presenting symptoms and imaging findings that are mistaken for other diagnoses (ie, subdural hematomas, Chiari malformation). Here, based on a comprehensive literature review, we describe the epidemiology, presentation, diagnostic workup and treatment of SIH.     

Bacteremia is as unpredictable as clinical manifestations in human brucellosis.

OBJECTIVES: Because of the suboptimal recovery rate of brucellae from blood, it has been proposed that cultures of bone marrow, liver tissue, and lymph nodes may improve the recovery rate of the organism. Data in support of these recommendations are limited and not clearly convincing, especially that of bone marrow culture. The main purpose of this work was to evaluate the roles of blood, bone marrow, liver, and lymph node cultures in the diagnosis of human brucellosis. METHODS: Blood and bone marrow cultures were evaluated in parallel in 103 cases of human brucellosis using Castaneda's biphasic technique. Simultaneous cultures of blood, bone marrow, liver, and lymph node aspirates were also carried out for 13 of these 103 cases. RESULTS: Blood culture identified 47 (45.6%) cases and bone marrow culture identified 85 (82.5%) cases. Faster recovery of Brucella spp was accomplished with the bone marrow culture (2.8+/-0.7 days, p<0.05). When the results of cultures of blood and bone marrow were compared with each other in the 13 cases, it was found that bone marrow specimens could be sterile (six cases (46%)) when bacteremia was present, but Brucella melitensis was detected in liver aspirate in all these six bacteremic cases. CONCLUSIONS: Our data indicate that it is worthwhile practicing bone marrow culture by conventional biphasic technique for the definitive and rapid diagnosis of brucellosis; this is particularly the case in developing countries where diagnostic facilities by advanced technologies such as automated culture systems with PCR are not available. Bone marrow culturing would be a better gold standard in areas where antibiotic pretreatment is common. Also, adopting the practice of culturing liver/lymph node fluids may enhance bacterial isolation and aid in the establishment of a diagnosis of brucellosis in cases for whom blood and bone marrow cultures are negative.