Effective rheumatoid arthritis treatment requires comprehensive management strategies

Work by Lee and colleagues has shown that decreased sleep quality and increased psychiatric distress increase pain sensitivity at both articular and nonarticular sites in rheumatoid arthritis (RA) patients. This work is consistent with prior studies showing that factors independent of RA disease activity can influence RA outcome measures. Owing to increasing pressure on rheumatologists to use outcome measures to inform treatment decisions, the work by Lee and colleagues highlights the need for comprehensive RA management strategies to understand and address the human factors that influence outcomes measures. Such strategies will ensure appropriate use of increasingly expensive therapies while maximizing patient satisfaction and reimbursement

A Comprehensive Evaluation of Standardized Assessment Tools in the Diagnosis of Fibromyalgia and in the Assessment of Fibromyalgia Severity

Standard assessments for fibromyalgia (FM) diagnosis and core FM symptom domains are needed for biomarker development and treatment trials. Diagnostic and symptom assessments are reviewed and recommendations are made for standards. Recommendations for existing assessments include the American College of Rheumatology FM classification criteria using the manual tender point Survey for diagnosis, the brief pain inventory average pain visual analogue scale for pain intensity, the function subscale of the revised fibromyalgia impact questionnaire (FIQR) for physical function, the patient global impression of change and FIQR for overall/global improvement, the hospital anxiety and depression scale depression subscale for depression, the multiple ability self-report questionnaire for cognitive dysfunction, the fatigue severity scale for fatigue, the FIQR for multidimensional function/health-related quality of life, the jenkins sleep scale for sleep disturbance, and the fibromyalgia intensity score for tenderness. Forthcoming assessments including the FIQR for diagnosis, NIH PROMIS, and FIBRO Change scales are discussed

Duloxetine for the management of fibromyalgia syndrome

Fibromyalgia syndrome (FMS) is a widespread pain condition associated with a wide range of additional symptoms including fatigue, insomnia, depression, anxiety and stiffness. Duloxetine is one of three medications currently FDA approved for use in FMS management. Duloxetine is a mixed serotonin and norepinephrine reuptake inhibitor (SNRI) that functions by increasing central nervous system levels of serotonin and norepinephrine. This review is a primer on use of duloxetine in FMS management and includes information on pharmacology and pharmacokinetics, a review of the three duloxetine FMS treatment trials currently in publication, a discussion of the safety and tolerability of duloxetine, and patient-focused perspectives on duloxetine use in FMS management. Duloxetine has proven efficacy in managing pain and mood symptoms in adult FMS patients with and without major depressive disorder. However, due to side effects, duloxetine must be used with caution in patients with fatigue, insomnia, gastrointestinal complaints, headache, cardiovascular disease, bleeding-risk, and in those 24 years of age and younger due to risk of suicidality. Duloxetine use should be avoided in patients with liver disease or alcoholics. As with all medications, duloxetine is best used as part of an individualized regimen that includes nonpharmacologic modalities of exercise, education and behavioral therapies

Duloxetine in the management of diabetic peripheral neuropathic pain

Diabetic neuropathy affects up to 70% of diabetics, and diabetic peripheral neuropathic pain (DPNP) is the most common and debilitating of the diabetic neuropathies. DPNP significantly reduces quality of life and increases management costs in affected patients. Despite the impact of DPNP, management is poor with one-quarter of patients receiving no treatment and many treated with medications having little or no efficacy in managing DPNP. Duloxetine is one of two drugs approved by the United States Food and Drug Administration for DPNP management. Duloxetine is a serotonin and norepinephrine reuptake inhibitor (SNRI) proven safe, effective, and cost-saving in reducing DPNP symptoms at a dose of 60 mg/day. Duloxetine doses greater than 60 mg/day for DPNP management are not recommended since they are no more efficacious and associated with more side effects; addition of pregabalin or gabapentin for these patients may be beneficial. Side effects of duloxetine are generally mild and typical for the SNRI class including nausea, dizziness, somnolence, fatigue, sweating, dry mouth, constipation, and diarrhea. Given its other indications, duloxetine is a particularly good choice for DPNP treatment in patients with coexisting depression, anxiety, fibromyalgia, or chronic musculoskeletal pain. Duloxetine treatment had no clinically significant effect on glycemic control and did not increase the risk of cardiovascular events in diabetes patients. However, duloxetine use should be avoided in patients with hepatic disease or severe renal impairment. Given its safety, efficacy, and tolerability, duloxetine is an excellent choice for DPNP treatment in many patients

Milnacipran for the management of fibromyalgia syndrome

Fibromyalgia syndrome (FMS) is a widespread pain condition associated with fatigue, cognitive dysfunction, sleep disturbance, depression, anxiety, and stiffness. Milnacipran is one of three medications currently approved by the Food and Drug Administration in the United States for the management of adult FMS patients. This review is the second in a three-part series reviewing each of the approved FMS drugs and serves as a primer on the use of milnacipran in FMS treatment including information on pharmacology, pharmacokinetics, safety and tolerability. Milnacipran is a mixed serotonin and norepinephrine reuptake inhibitor thought to improve FMS symptoms by increasing neurotransmitter levels in descending central nervous system inhibitory pathways. Milnacipran has proven efficacy in managing global FMS symptoms and pain as well as improving symptoms of fatigue and cognitive dysfunction without affecting sleep. Due to its antidepressant activity, milnacipran can also be beneficial to FMS patients with coexisting depression. However, side effects can limit milnacipran tolerability in FMS patients due to its association with headache, nausea, tachycardia, hyper- and hypotension, and increased risk for bleeding and suicidality in at-risk patients. Tolerability can be maximized by starting at low dose and slowly up-titrating if needed. As with all medications used in FMS management, milnacipran works best when used as part of an individualized treatment regimen that includes resistance and aerobic exercise, patient education and behavioral therapies

Perceptual and production training of intervocalic /d, Q, r/ in American English learners of Spanish

This is the publisher's version, also available electronically from: http://dx.doi.org/10.1121/1.4802902.This study investigates the effectiveness of three high variability training paradigms in training 42 speakers of American English to correctly perceive and produce Spanish intervocalic /d, ɾ, r/. Since Spanish spirantization and English flapping both affect /d/ intervocalically, the acquisition of the /d/-/ɾ/ contrast proves difficult for English learners of Spanish. The acquisition of the trill /r/ is also problematic because it is a new phoneme for English learners and is articulatorily difficult to produce. Past research reported that high-variability perceptual training improves both perception and production [Bradlow et al., J. Acoust. Soc. Am. 101, 2299–2310 (1997); Wang et al., J. Acoust. Soc. Am. 113, 1033–1043 (2003)] and that production training improves both as well [Hirata, Comp. Assisted Lang. Learning 17, 357–376 (2004)]. However, trainees were able to listen to stimuli during production training, making it unclear whether production training alone transfers to perception. This study systematically controls both training modalities so they can be directly compared and introduces a third training methodology that includes both perception and production. All three training paradigms proved effective. While perception and production trainees primarily made gains in perception, combination trainees made gains in production. The effectiveness of each training modality depended on the nature of the contrast being trained and the modality of the test

L2 perception of Spanish palatal variants across different tasks

While considerable dialectal variation exists, almost all varieties of Spanish exhibit some sort of alternation in terms of the palatal obstruent segments. Typically, the palatal affricate [ɟʝ] tends to occur in word onset following a pause and in specific linear phonotactic environments. The palatal fricative [ʝ] tends to occur in syllable onset in other contexts. We show that listeners’ perceptual sensitivity to the palatal alternation depends upon the task and exposure to Spanish input. For native Spanish listeners, the palatal alternation boosts segmentation accuracy on an artificial speech segmentation task and also reduces latencies on a phonotactically-conditioned elision task. L2 Spanish listeners, on the other hand, only benefit from the palatal alternation in the second task. These results suggest that while Spanish L2 learners benefit from the presence of the alternation in linear phonotactic terms, this benefit does not carry over to a more abstract segmentation task

Obtaining high resolution excitation functions with an active thick-target approach and validating them with mirror nuclei

Measurement of fusion excitation functions for stable nuclei has largely been restricted to nuclei with significant natural abundance. Typically, to investigate neighboring nuclei with low natural abundance has required obtaining isotopically enriched material. This restriction often limits the ability to perform such measurements. We report the measurement of a high quality fusion excitation function for a $^{17}$O beam produced from unenriched material with 0.038\% natural abundance. The measurement is enabled by using an active thick-target approach and the accuracy of the result is validated using its mirror nucleus $^{17}$F and resonances. The result provides important information about the average fusion cross-section for the oxygen isotopic chain as a function of neutron excess.Comment: 4 pages, 4 figure