Klinikum Saarbrücken

In this proof-of-concept study, we introduce and demonstrate MXene as a novel type of intercalation electrode for desalination <italic>via</italic> capacitive deionization (CDI).

OBJECTIVE: To evaluate fibromyalgia in the general population with emphasis on prevalence, dimensionality, and somatic symptom severity. METHODS: We studied 2,445 subjects randomly selected from the German general population in 2012 using the American College of Rheumatology 2010 preliminary diagnostic criteria for fibromyalgia, as modified for survey research, and the polysymptomatic distress scale (PSD). Anxiety, depression, and somatic symptom severity were assessed with the Patient Health Questionnaire (PHQ) series, and measures of symptoms and quality of life were assessed with the European Organization for Research and Treatment of Cancer questionnaire. RESULTS: The prevalence of fibromyalgia was 2.1% (95% confidence interval [95% CI] 1.6, 2.7), with 2.4% (95% CI 1.5, 3.2) in women and 1.8% (95% CI 1.1, 2.6) in men, but the difference was not statistically significant. Prevalence rose with age. Fibromyalgia subjects had markedly abnormal scores for all covariates. We found smooth, nondisordered relationships between PSD and all predictors, providing additional evidence against the hypothesis that fibromyalgia is a discrete disorder and in support of a dimensional or spectrum disorder. There was a strong correlation (r = 0.790) between the PSD and the PHQ somatic symptom severity scale; 38.5% of persons with fibromyalgia satisfied the proposed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for a physical symptom disorder. CONCLUSION: The modified 2010 diagnostic criteria do not result in high levels of fibromyalgia. PSD and fibromyalgia are strongly related to somatic symptom severity. There is evidence in support of fibromyalgia as a dimensional or continuum disorder. This has important ramifications for neurobiologic and epidemiology research, and for clinical diagnosis, treatment, and ascertainment of disability.

INTRODUCTION: The efficacy and the optimal type and volume of aerobic exercise (AE) in fibromyalgia syndrome (FMS) are not established. We therefore assessed the efficacy of different types and volumes of AE in FMS. METHODS: The Cochrane Library, EMBASE, MEDLINE, PsychInfo and SPORTDISCUS (through April 2009) and the reference sections of original studies and systematic reviews on AE in FMS were systematically reviewed. Randomised controlled trials (RCTs) of AE compared with controls (treatment as usual, attention placebo, active therapy) and head-to-head comparisons of different types of AE were included. Two authors independently extracted articles using predefined data fields, including study quality indicators. RESULTS: Twenty-eight RCTs comparing AE with controls and seven RCTs comparing different types of AE with a total of 2,494 patients were reviewed. Effects were summarised using standardised mean differences (95% confidence intervals) by random effect models. AE reduced pain (-0.31 (-0.46, -0.17); P<0.001), fatigue (-0.22 (-0.38, -0.05); P=0.009), depressed mood (-0.32 (-0.53, -0.12); P=0.002) and limitations of health-related quality of life (HRQOL) (-0.40 (-0.60, -0.20); P<0.001), and improved physical fitness (0.65 (0.38, 0.95); P<0.001), post treatment. Pain was significantly reduced post treatment by land-based and water-based AE, exercises with slight to moderate intensity and frequency of two or three times per week. Positive effects on depressed mood, HRQOL and physical fitness could be maintained at follow-up. Continuing exercise was associated with positive outcomes at follow-up. Risks of bias analyses did not change the robustness of the results. Few studies reported a detailed exercise protocol, thus limiting subgroup analyses of different types of exercise. CONCLUSIONS: An aerobic exercise programme for FMS patients should consist of land-based or water-based exercises with slight to moderate intensity two or three times per week for at least 4 weeks. The patient should be motivated to continue exercise after participating in an exercise programme.

Engineering a large IP backbone network without an accurate network-wide view of the traffic demands is challenging. Shifts in user behavior, changes in routing policies, and failures of network elements can result in significant (and sudden) fluctuations in load. We present a model of traffic demands to support traffic engineering and performance debugging of large Internet service provider networks. By defining a traffic demand as a volume of load originating from an ingress link and destined to a set of egress links, we can capture and predict how routing affects the traffic traveling between domains. To infer the traffic demands, we propose a measurement methodology that combines flow-level measurements collected at all ingress links with reachability information about all egress links. We discuss how to cope with situations where practical considerations limit the amount and quality of the necessary data. Specifically, we show how to infer interdomain traffic demands using measurements collected at a smaller number of edge links-the peering links connecting to neighboring providers. We report on our experiences in deriving the traffic demands in the AT&T IP Backbone, by collecting, validating, and joining very large and diverse sets of usage, configuration, and routing data over extended periods of time. The paper concludes with a preliminary analysis of the observed dynamics of the traffic demands and a discussion of the practical implications for traffic engineering.

Abstract Objective To systematically review the efficacy of multicomponent treatment of fibromyalgia syndrome (FMS). Methods We screened Medline, PsychINFO, Scopus, and the Cochrane Library (through December 2007), as well as reference sections of original studies, reviews, and evidence‐based guidelines. Randomized controlled trials (RCTs) on the multicomponent treatment (at least 1 educational or other psychological therapy with at least 1 exercise therapy) of FMS were analyzed. Results We included 9 (of 14) RCTs with 1,119 subjects (median treatment time 24 hours) in the meta‐analysis. Effects were summarized using standardized mean differences (SMDs) or weighted mean differences (WMDs). There was strong evidence that multicomponent treatment reduces pain (SMD −0.37; 95% confidence interval [95% CI] −0.62, −0.13), fatigue (WMD −0.85; 95% CI −1.50, −0.20), depressive symptoms (SMD −0.67; 95% CI −1.08, −0.26), and limitations to health‐related quality of life (HRQOL) (SMD −0.59; 95% CI −0.90, −0.27) and improves self‐efficacy pain (SMD 0.54; 95% CI 0.26, 0.82) and physical fitness (SMD 0.30; 95% CI 0.02, 0.57) at posttreatment. There was no evidence of its efficacy on pain, fatigue, sleep disturbances, depressive symptoms, HRQOL, or self‐efficacy pain in the long term. There was strong evidence that positive effects on physical fitness (SMD 0.30; 95% CI 0.09, 0.51) can be maintained in the long term (median followup 7 months). Conclusions There is strong evidence that multicomponent treatment has beneficial short‐term effects on the key symptoms of FMS. Strategies to maintain the benefits of multicomponent treatment in the long term need to be developed.

The Childhood Trauma Questionnaire (CTQ) has become internationally accepted as an assessment of traumatic childhood experiences. The short version assesses aspects of childhood abuse and neglect. In order to check the psychometric properties of the German short form, the CTQ was used within a representative sample of the German population (N=2 500). The five factor structure of the original version showed only a sufficient model fit, because of high intercorrelations and weak internal consistency of the scale "physical neglect". The internal consistency of the other subscales was high with α≥0.80. Construct validity was supported by positive correlations with measures of anxiety/depression and negative correlations with life satisfaction. The German short form of the CTQ is a reliable and valid self rating instrument to assess childhood maltreatment retrospectively. The subscale "physical neglect" should be applied with caution.

We compared the methodology and the recommendations of evidence-based guidelines for the management of fibromyalgia syndrome (FMS) to give an orientation within the continuously growing number of reviews on the therapy of FMS. Systematic searches up to April 2008 of the US-American National Guideline Clearing House, the Scottish Intercollegiate Guidelines Network, the Association of the Scientific Medical Societies in Germany (AWMF) and Medline were conducted. Three evidence-based guidelines for the management of FMS published by professional organizations were identified: The American Pain Society (APS) (2005), the European League Against Rheumatism (EULAR) (2007), and the AWMF (2008). The steering committees and panels of APS and AWMF were comprised of multiple disciplines engaged in the management of FMS and included patients, whereas the task force of EULAR only consisted of physicians, predominantly rheumatologists. APS and AWMF ascribed the highest level of evidence to systematic reviews and meta-analyses, whereas EULAR credited the highest level of evidence to randomised controlled studies. Both APS and AWMF assigned the highest level of recommendation to aerobic exercise, cognitive-behavioral therapy, amitriptyline, and multicomponent treatment. In contrast, EULAR assigned the highest level of recommendation to a set of to pharmacological treatment. Although there was some consistency in the recommendations regarding pharmacological treatments among the three guidelines, the APS and AWMF guidelines assigned higher ratings to CBT and multicomponent treatments. The inconsistencies across guidelines are likely attributable to the criteria used for study inclusion, weighting systems, and composition of the panels.

CONTEXT: Fibromyalgia syndrome (FMS) is a chronic pain disorder associated with multiple debilitating symptoms and high disease-related costs. Effective treatment options are needed. OBJECTIVES: To determine the efficacy of antidepressants in the treatment of FMS by performing a meta-analysis of randomized controlled clinical trials. DATA SOURCES: MEDLINE, PsycINFO, Scopus, and the Cochrane Library databases were searched through August 2008. Reference sections of original studies, meta-analyses, and reviews on antidepressants in FMS were reviewed. STUDY SELECTION: Randomized placebo-controlled trials with tricyclic and tetracyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin and noradrenaline reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs) were analyzed. DATA EXTRACTION AND DATA SYNTHESIS: Two authors independently extracted data. Effects were summarized using standardized mean differences (SMDs) by a random-effects model. RESULTS: Eighteen randomized controlled trials (median duration, 8 weeks; range, 4-28 weeks) involving 1427 participants were included. Overall, there was strong evidence for an association of antidepressants with reduction in pain (SMD, -0.43; 95% confidence interval [CI], -0.55 to -0.30), fatigue (SMD, -0.13; 95% CI, -0.26 to -0.01), depressed mood (SMD, -0.26; 95% CI, -0.39 to -0.12), and sleep disturbances (SMD, -0.32; 95% CI, -0.46 to -0.18). There was strong evidence for an association of antidepressants with improved health-related quality of life (SMD, -0.31; 95% CI, -0.42 to -0.20). Effect sizes for pain reduction were large for TCAs (SMD, -1.64; 95% CI, -2.57 to -0.71), medium for MAOIs (SMD, -0.54; 95% CI, -1.02 to -0.07), and small for SSRIs (SMD, -0.39; 95% CI, -0.77 to -0.01) and SNRIs (SMD, -0.36; 95% CI, -0.46 to -0.25). CONCLUSION: Antidepressant medications are associated with improvements in pain, depression, fatigue, sleep disturbances, and health-related quality of life in patients with FMS.

PURPOSE: Multiple clinical and epidemiological studies have provided estimates of fibromyalgia prevalence and sex ratio, but different criteria sets and methodology, as well as bias, have led to widely varying (0.4%->11%) estimates of prevalence and female predominance (>90% to <61%). In general, studies have failed to distinguish Criteria based fibromyalgia (CritFM) from Clinical fibromyalgia (ClinFM). In the current study we compare CritFM with ClinFM to investigate gender and other biases in the diagnosis of fibromyalgia. METHODS: We used a rheumatic disease databank and 2016 fibromyalgia criteria to study prevalence and sex ratios in a selection biased sample of 1761 referred and diagnosed fibromyalgia patients and in an unbiased sample of 4342 patients with no diagnosis with respect to fibromyalgia. We compared diagnostic and clinical variables according to gender, and we reanalyzed a German population study (GPS) (n = 2435) using revised 2016 criteria for fibromyalgia. RESULTS: In the selection-biased sample of referred patients with fibromyalgia, more than 90% were women. However, when an unselected sample of rheumatoid arthritis (RA) patients was studied for the presence of fibromyalgia, women represented 58.7% of fibromyalgia cases. Women had slightly more symptoms than men, including generalized pain (36.8% vs. 32.4%), count of 37 symptoms (4.7 vs. 3.7) and mean polysymptomatic distress scores (10.2 vs. 8.2). We also found a linear relation between the probability of being females and fibromyalgia and fibromyalgia severity. Women in the GPS represented 59.2% of cases. DISCUSSION: The perception of fibromyalgia as almost exclusively (≥90%) a women's disorder is not supported by data in unbiased studies. Using validated self-report criteria and unbiased selection, the female proportion of fibromyalgia cases was ≤60% in the unbiased studies, and the observed CritFM prevalence of fibromyalgia in the GPS was ~2%. ClinFM is the public face of fibromyalgia, but is severely affected by selection and confirmation bias in the clinic and publications, underestimating men with fibromyalgia and overestimating women. We recommend the use of 2016 fibromyalgia criteria for clinical diagnosis and epidemiology because of its updated scoring and generalized pain requirement. Fibromyalgia and generalized pain positivity, widespread pain (WPI), symptom severity scale (SSS) and polysymptomatic distress (PSD) scale should always be reported.

1. Introduction The COVID-19 pandemic has impacted the lives and health of persons worldwide, with potential for further effects in the future. The experience of living within this pandemic has disrupted daily life across all sectors, including those living with chronic pain (CP), those infected with the coronavirus Severe Acute Respiratory Syndrome (SARS)-CoV2, healthcare providers and essential workers, as well as those who remained physically healthy. The toll of this pandemic extends beyond physical illness, with important psychosocial stressors that include prolonged periods of limited interpersonal contact, isolation, fear of illness, future uncertainty, and financial strain. Uncertainty is fuelled by the constant media coverage, often with conflicting information, differing recommendations by public health authorities in different jurisdictions, and the unknown duration and likelihood of resurgence of this pandemic. In this context, we will examine the potential health consequences of COVID-19 germane to CP, which might be nociplastic, neuropathic, or nociceptive. Specific possibilities might include: (1) CP as part of a postviral syndrome or the result of viral-associated organ damage; (2) worsening of CP due to exacerbation of preexisting pain physical or mental complaints; and (3) CP newly triggered in individuals not infected with COVID by exacerbation of risk factors (poor sleep, inactivity, fear, anxiety, and depression). Chronic pain must be considered in the context of the biopsychosocial model, which views symptoms as the result of a complex and dynamic interaction between biological, psychological, and social factors.36,39 Underlying predisposing mechanisms include genetic factors, previous pain experience, and traumatic events that could be physical or emotional.2 Chronic pain conditions can be triggered by psychosocial stressors or organ-specific biological factors, which may preferentially occur in individuals with a fragile stress response system.8,10,24,40,47 The COVID-19 pandemic has many characteristics that could potentially increase the prevalence of CP, especially with stressors extending over many months. The worldwide pain community is invited to consider the possible downstream consequences of COVID-19, not only for patients surviving infection, but also for the wider community that has experienced psychological, social, and economic effects. Although we address these issues from the perspective of physicians practicing in developed countries, many of the consequences discussed will be particularly relevant for people in other countries, with a call for colleagues in Asia, Africa, and South America to enter into this dialogue. 2. Infections as a trigger for chronic pain Acute viral illnesses often present with myalgia and fatigue, as well as organ-specific symptoms, as seen with influenza, and noted in the H1N1 pandemics of 1918 and 2009, and coronavirus infection during the SARS epidemic.4,17 Outcomes related to these infections are almost always focused on the immediate response to the acute illness, with little attention to long-term outcomes. In a small study of 22 subjects (21 of whom were healthcare workers) infected during the SARS epidemic, a chronic post-SARS syndrome consisting of fatigue, diffuse myalgia, depression, and nonrestorative sleep persisted for almost 2 years.27 Similarly, some patients with chronic widespread pain report onset of symptoms after a perceived viral illness. Although some infections cause specific postinfectious syndromes, there is also a common stereotypical response to any type of infection that is often observed. For example, up to 12% of patients infected with 3 different pathogens, ie, Ross River virus (the cause of epidemic polyarthritis), Coxiella burnetii (cause of Q fever), and Epstein–Barr virus, experienced a postviral syndrome of pain, fatigue, and memory difficulties for up to 12 months after infection.15 Although these infections have markedly disparate acute presentations, a stereotypical chronic syndrome occurred at remarkably similar rates and was not predicted by demographic, psychological/psychiatric measures, or microbiological factors.15 The presence and severity of somatic symptoms during acute infection was closely correlated with the subsequent development of chronic fatigue and pain. Chronic regional pain and other somatic symptoms can follow other types of acute infection. In a meta-analysis, Halvorson et al. noted that approximately 10% of individuals will develop postinfectious irritable bowel syndrome after an episode of acute viral or bacterial gastroenteritis, with premorbid psychological problems and/or psychosocial stressors recognized as risk factors.7,13 On a similar note, an episode of acute urinary tract infection is evident in a substantial proportion of women who develop interstitial cystitis/painful bladder syndrome.43 Collectively, these findings imply that various acute infections are capable of triggering both widespread and regional CP. The evidence also suggests that the inciting infection must be of sufficient severity and duration to disrupt normal activities.44 Current estimates are that 80% of laboratory-confirmed COVID-19 patients have mild to moderate disease, including both pneumonia and nonpneumonia cases, 13.8% have severe disease, and 6.1% develop critical illness requiring intensive care unit (ICU) admission.42 3. Potential health-related consequences of COVID-19 3.1. Chronic pain as a consequence of COVID-19 disease Persons with COVID-19 may exhibit a broad range of symptoms, beginning with those who are asymptomatic and extending to patients who develop full-blown severe respiratory distress syndrome. Nonspecific constitutional symptoms include fatigue, myalgias, chills, and headaches. Most patients experience symptoms for 1 to 2 weeks with complete resolution, although some require hospitalization. The mortality rate of COVID-19 is on the order of 1% according to estimates published by the Centre for Evidence-Based Medicine.37 Whether patients with CP are more susceptible to viral infection or the consequences thereof is unknown. Theoretically, the diminished immune response system observed in CP patients could be even further suppressed by factors such as depression, poor sleep, and opioid use, with potential to increase susceptibility to SARS-CoV2.19,41 Many individuals with COVID need ICU care, and individuals surviving an illness requiring ICU admission are at increased risk of long-lasting severe functional limitations, psychological distress, and CP. Surveys have reported persistent CP in 38% to 56% of ICU survivors when evaluated 2 to 4 years after ICU admission.18,34 Quality of life can also be affected for prolonged periods. In a study evaluating 575 patients 6 to 11 years after ICU discharge, many experienced persistent difficulty with mobility (52%), self-care (19%), activities of daily living (52%), pain/discomfort (57%), and cognition (43%).38 Mental health is also frequently affected by severe illness. Between 41% and 65% of SARS survivors have experienced persistent psychological symptoms.20,23 Between 25% and 44% of Hong Kong residents who were infected with SARS and survived were diagnosed with posttraumatic stress disorder (PTSD), and 15% experienced depression for at least 30 months after the illness.16,22 Posttraumatic stress disorder also occurred in 40.7% of SARS-infected healthcare workers.22 3.2. Exacerbation of chronic pain in the absence of actual infection Some CP patients may experience exacerbation of symptoms resulting from COVID-19 due to both public health and personal issues. Regular medical care may be compromised during lockdown and the ensuing months.9 Routine clinics may be less accessible or closed, healthcare professionals may be diverted to COVID-19-related activities, and waiting times may be prolonged, especially for medical illnesses such as CP that many consider nonurgent. Patients may be less able or willing to travel for care, or may be fearful of exposure to infection in a public or medical setting. There may be delays in timely access to medications due to reduced prescribing, as well as to pain management procedures considered to be of lesser importance than the care of patients with more urgent illnesses. Reduced clinical encounters with interdisciplinary healthcare team members (eg, physiotherapists, psychologists, and self-help groups) can have adverse consequences. Access to medications may be reduced due to logistical factors or true drug shortages when analgesic medications are diverted to emergency care causing some to turn to alcohol or nonmedically prescribed substances as a desperate measure to relieve poorly managed pain. The rapid evolution of telehealth presents new challenges for clinical care, especially for those not fully comfortable with or without access to digital technology. The economic impact on public health is evident for working patients who may have lost jobs or health insurance and must contend with financial insecurity or even poverty. Another factor to consider is reduced health-related physical activities, which are a vital management strategy for CP, that result from social distancing and isolation, and closure of group activity programs such as gyms and pools.21 Limited social support will also contribute to poor psychological health.12 Patients may have a heightened awareness of physical symptoms accompanied by fear that these symptoms are an indication of infection. These numerous and persistent stressors may exacerbate pain, even in the absence of viral illness. Given these factors, common wisdom might suggest that catastrophic and stressful events such as COVID-19 will inevitably lead to an exacerbation of CP. However, 2 studies performed in the United States just before and after the 9/11 terrorist attacks indicate that not all psychological stressors will trigger or exacerbate CP. Pain complaints and other somatic symptoms did not change among residents of New York and New Jersey who had been surveyed before and after the 9/11 attacks on the World Trade Center.32 Similarly, pain complaints did not change for patients with fibromyalgia in the Washington, D.C. region during the same period.32 Daily “hassles” and personally relevant stressors seem to be more likely to cause symptoms than major catastrophic events that do not personally impact the individual.30 Therefore, the duration of the stress (ie, weeks to months of lockdown in the current pandemic), and the vocational uncertainty and actual loss of jobs, may adversely affecting health outcomes. Reviews that highlight the role that various catastrophic events have on health suggest a number of factors that may be more important than the intensity of the “stressor” in predicting adverse health outcomes. Female sex, concerns about or the expectation of chronicity, and inactivity or time off work can all trigger pain and other somatic symptoms.26 Naturally occurring catastrophic events such as earthquakes, floods, or fires seem less likely to lead to chronic somatic symptoms than similarly “man-made” stressful events such as chemical spills or war.6 Exposure to a multitude of stressors simultaneously, or over time, may also pose significant risk for later somatic and/or psychological sequelae.14,33 For example, in military personnel, multiple deployments significantly increase the risk for PTSD and other psychiatric conditions, which in turn are highly coprevalent with CP.46 3.3. New onset of chronic pain related to psychological stressors It is not currently known whether COVID-19 will cause an increase in new-onset CP for the population at large. Risk factors for the longitudinal development of CP have been well studied in fibromyalgia and temporomandibular disorders.11,25,29 Although CP conditions are thought by some to be highly related to stress and distress, studies have consistently shown that high baseline levels of psychological distress are only modestly related to the development of chronic regional or widespread pain (OR 1.5-2).25 Regional CP, female sex, and low socioeconomic status are the strongest predictors for the subsequent development of widespread pain.11,25 Other factors that may contribute to an increase in CP are poor sleep and reduced physical activity. Sleep deprivation can lead to symptoms virtually indistinguishable from widespread pain, fatigue, and diffuse tenderness.28 Furthermore, the effects of sleep deprivation may be attenuated by physical activity (ie, individuals who remain physically active may be less sensitive to the effects of sleep disruption).1 Healthcare workers may be at increased risk for development of CP. In a recent Israeli study, 9.7% of a cohort of 206 nurses fulfilled criteria for fibromyalgia, with symptoms strongly correlated with work-related stress and PTSD-related symptoms.3 Numerous factors contribute to high stress levels across geographic boundaries. Nearly everyone is exposed to relentless media coverage and conflicting messages, and concerns about contracting SARS-CoV2, routine medical care, family, jobs, and economic issues are pervasive. Those with an underlying mental health disorder are at particular risk for exacerbation. Further stressors relate to social distancing, isolation and quarantine, and in some, grieving a death without the usual social support system. Persistent and extreme stress can lead to severe mental health consequences including an increased suicide rate. There is preliminary evidence that anxiety and depression (16%-28%), self-reported stress (8%), and sleep disturbances are common reactions to this pandemic.31 During the SARS outbreak in 2003, an historically high suicide rate of 18.6 per 100,000 was reported in Hong Kong.5 Furthermore, the annual suicide rate in older adults after the SARS epidemic did not return to preepidemic levels, suggesting that factors related to the epidemic had long-term consequences. 4. Immediate consequences of COVID-19 and strategies to mitigate these effects Recovery from a life-threatening illness can be expected to affect future physical and mental health. Rehabilitation services should be mobilized for both inpatient and outpatient care, with attention paid to staffing issues to ensure access to psychological services, physiotherapy, and occupational therapy.35 Routine medical care will resume for most patients, and healthcare professionals should be flexible and willing to adapt to new methods of healthcare delivery, especially with regard to telemedicine.9 Healthcare workers must also adapt to different methods of communicating with colleagues and an increased emphasis on virtual learning and teaching. Those working in mental health must be attuned to the consequences of economic hardship, which could include increased substance abuse, domestic violence, and suicide. Providers working in low- and middle-income countries are particularly disadvantaged by limited healthcare resources and a shortage of healthcare workers.45 Developed countries should recognize that healthcare crises in underdeveloped countries are constrained by artificial boundaries and continue to participate in efforts led by international organizations such the World Health Organization and International Red Cross. These suggestions can only be implemented if governments and legislators are willing to work in partnership with the healthcare community in accordance with the recommendations of experts. 5. Conclusion In this unprecedented crisis, the immediate healthcare concerns are directed towards containment and acute patient care. The impact of the COVID-19 pandemic on health will likely be manifested in both infected individuals and in people spared infection, but are nevertheless adversely affected by disruptions in normal life and experience a wide array of physical, psychological, and social stressors. Based on past experience, we postulate that these scenarios may collectively lead to an increase in CP in the immediate and possibly long-term future. Amidst many uncertainties, the research community is urged to study, devise, and implement strategies aimed at mitigating the pain-related health consequences of this pandemic. Some suggestions could include the establishment of registries of infected patients (including those with concomitant CP), designated COVID-19-related clinics to ensure new and follow-up care for infected persons, examination of telehealth as a means of delivering health care, and population surveys to gather public health information related to COVID-19. Epidemiological data should be used to inform future healthcare policies that seek to reduce the magnitude of future epidemics and their myriad consequences on CP and other diseases. The timely recognition of new CP or exacerbations of preexisting CP, prompt and targeted treatment, and strategies to mitigate the potential impact on health are strongly encouraged. Conflict of interest statement D.J. Clauw has performed consulting for Pfizer, Tonix, Samumed, Lilly, and Aptinyx, and has received research funding from Aptinyx. S.P. Cohen is supported by a grant from the U.S. Dept. of Defense, Uniformed Services University, Department of Physical Medicine & Rehabilitation, Musculoskeletal Injury Rehabilitation Research for Operational Readiness (MIRROR) (HU00011920011). The remaining authors have no conflicts of interest to declare.

When switching from two-lung to one-lung ventilation (OLV), shunt fraction increases, oxygenation is impaired, and hypoxemia may occur. Hypoxemia during OLV may be predicted from measurements of lung function, distribution of perfusion between the lungs, whether the right or the left lung is ventilated, and whether the operation will be performed in the supine or in the lateral decubitus position. Hypoxemia during OLV may be prevented by applying a ventilation strategy that avoids alveolar collapse while minimally impairing perfusion of the dependent lung. Choice of anesthesia does not influence oxygenation during clinical OLV. Hypoxemia during OLV may be treated symptomatically by increasing inspired fraction of oxygen, by ventilating, or by using continuous positive airway pressure in the nonventilated lung. Hypoxemia during OLV may be treated causally by correcting the position of the double-lumen tube, clearing the main bronchi of the ventilated lung from secretions, and improving the ventilation strategy.

Abstract Sandwich panels consisting of a highly porous aluminium foam core and aluminium alloy face sheets are manufactured by roll‐bonding aluminium alloy sheets to a densified mixture of metal powders – usually Al‐Si or Al‐Si‐Cu alloys with 6–8% Si and 3–10% Cu – and titanium hydride, and foaming the resulting three‐layer structure by a thermal treatment. We review the various processing steps of aluminium foam sandwich (AFS) and the metallurgical processes during foaming, compare the process to alternative ways to manufacture AFS, e.g. by adhesive bonding, and give an overview of the available literature. Two ways to treat AFS after foaming are presented, namely forging and age‐hardening. Some current and potential applications are described and the market potential of AFS is assessed.

OBJECTIVES: To evaluate and compare the efficacy and acceptability of the antidepressants amitriptyline (AMT), duloxetine (DLX) and milnacipran (MLN) for FM syndrome (FMS). METHODS: Cochrane Library, MEDLINE, SCOPUS, www.clinicalstudyresults.org and www.clinicalTrials.gov were searched for randomized pharmacological placebo-controlled trials until 30 May 2010. Outcomes of interest were symptom reduction [pain, fatigue, sleep disturbance and reduced health-related quality of life (HRQOL)] and acceptability (total drop-out rates). We performed a meta-analysis of each drug vs placebo using a random-effects model and adjusted indirect analyses of the three drugs. Methodological quality was assessed by the Cochrane risk of bias tool. RESULTS: Ten AMT studies (612 patients), four DLX studies (1411 patients) and five MLN studies (4129 patients) met the inclusion criteria. The reported methodological quality of most AMT trials was poor, that of DLX and MLN were high. The three drugs were superior to placebo except DLX for fatigue, MLN for sleep disturbance and AMT for HRQOL. The significant effects of AMT and DLX were small and those of MLN not substantial. In adjusted indirect comparisons, AMT was superior to DLX and MLN in reduction of pain, sleep disturbances, fatigue and limitations of HRQOL. DLX was superior to MLN in reducing pain, sleep disturbances and limitations of HRQOL. MLN was superior to DLX in reducing fatigue. There were no significant differences in acceptability of the three drugs. CONCLUSIONS: AMT cannot be regarded as the gold standard of FMS therapy with antidepressants because of the methodological limitations of its trials.

BACKGROUND: There are no up-to-date, representative studies on the frequency of maltreatment (abuse or neglect) among children and adolescents in Germany. METHODS: In a cross-sectional study, standardized questionnaires were administered to persons aged 14 and older in a representative sample of the German population. Statistics on maltreatment in childhood and adolescence were collected with the German version of the Childhood Trauma Questionnaire. Regression analysis was used to detect potential associations of maltreatment with demographic variables including sex, age, place of birth, and social class. RESULTS: 2504 of the 4455 persons contacted (56%) completed the study. Severe emotional abuse in childhood and/or adolescence was reported by 1.6% of persons in the overall sample, severe physical abuse by 2.8%, and severe sexual abuse by 1.9%. Severe emotional neglect was reported by 6.6% and severe physical neglect by 10.8%. Female sex was a predictor for severe sexual abuse, while belonging to a low or middle social stratum was a predictor for severe physical abuse and neglect. Being older at the time of the survey was a predictor for severe physical neglect. All types of maltreatment were significantly correlated with each other (p<0.001). CONCLUSION: The frequencies of various types of abuse and neglect of children and adolescents that were retrospectively determined in this up-to-date study by questionnaire of a representative sample of the German population, and the correlations between them, correspond to those found in a German population-based study in 1995 and in recent American studies.

The invention of the polymerase chain reaction (PCR) has caused a revolution in molecular biology, giving access to a method of amplifying deoxyribonucleic acid (DNA) molecules across several orders of magnitude. Since the first application of PCR in a microfluidic device was developed in 1998, an increasing number of researchers have continued the development of microfluidic PCR systems. In this review, we introduce recent developments in microfluidic-based space and time domain devices as well as discuss various designs integrated with multiple functions for sample preparation and detection. The development of isothermal nucleic acid amplification and digital PCR microfluidic devices within the last five years is also highlighted. Furthermore, we introduce various commercial microfluidic PCR devices.

Behavioral exposure therapy of anxiety disorders is believed to rely on fear extinction. Because preclinical studies have shown that glucocorticoids can promote extinction processes, we aimed at investigating whether the administration of these hormones might be useful in enhancing exposure therapy. In a randomized, double-blind, placebo-controlled study, 40 patients with specific phobia for heights were treated with three sessions of exposure therapy using virtual reality exposure to heights. Cortisol (20 mg) or placebo was administered orally 1 h before each of the treatment sessions. Subjects returned for a posttreatment assessment 3-5 d after the last treatment session and for a follow-up assessment after 1 mo. Adding cortisol to exposure therapy resulted in a significantly greater reduction in fear of heights as measured with the acrophobia questionnaire (AQ) both at posttreatment and at follow-up, compared with placebo. Furthermore, subjects receiving cortisol showed a significantly greater reduction in acute anxiety during virtual exposure to a phobic situation at posttreatment and a significantly smaller exposure-induced increase in skin conductance level at follow-up. The present findings indicate that the administration of cortisol can enhance extinction-based psychotherapy.

OBJECTIVE: We performed the first systematic review with metaanalysis of the efficacy of cognitive-behavioral therapies (CBT) in fibromyalgia syndrome (FM). METHODS: We screened Cochrane Library, Medline, PsychINFO, and Scopus (through June 2009) and the reference sections of original studies and systematic reviews for CBT in FM. Randomized controlled trials (RCT) comparing CBT to controls were analyzed. Primary outcomes were pain, sleep, fatigue, and health-related quality of life (HRQOL). Secondary outcomes were depressed mood, self-efficacy pain, and healthcare-seeking behavior. Effects were summarized using standardized mean differences (SMD). RESULTS: A total of 14 out of 27 RCT with 910 subjects with a median treatment time of 27 hours (range 6-75) over a median of 9 weeks (range 5-15) were included. CBT reduced depressed mood (SMD -0.24, 95% CI -0.40, -0.08; p = 0.004) at posttreatment. Sensitivity analyses showed that the positive effect on depressed mood could not be distinguished from some risks of bias. There was no significant effect on pain, fatigue, sleep, and HRQOL at posttreatment and at followup. There was a significant effect on self-efficacy pain posttreatment (SMD 0.85, 95% CI 0.25, 1.46; p = 0.006) and at followup (SMD 0.90, 95% CI 0.14, 1.66; p = 0.02). Operant behavioral therapy significantly reduced the number of physician visits at followup (SMD -1.57, 95% CI -2.00, -1.14; p < 0.001). CONCLUSION: CBT can be considered to improve coping with pain and to reduce depressed mood and healthcare-seeking behavior in FM.

BACKGROUND: To perform a systematic review and meta-analysis on cytokine levels in patients with fibromyalgia syndrome (FMS). METHODS: Through December 2010 we systematically reviewed the databases PubMed, MEDLINE, and PsycINFO and screened the reference lists of 22 review articles for suitable original articles. Original articles investigating cytokines in patients with FMS were included. Data were extracted by two independent authors. Differences of the cytokine levels of FMS patients and controls were summarized by standardized mean differences (SMD) using a random effects model. Study quality was assessed applying methodological scores: modified Center of Evidence Based Medicine, Newcastle-Ottawa-Scale, and Würzburg Methodological Quality Score. RESULTS: Twenty-five articles were included investigating 1255 FMS patients and 800 healthy controls. Data of 13/25 studies entered meta-analysis. The overall methodological quality of studies was low. The results of the majority of studies were not comparable because methods, investigated material, and investigated target cytokines differed. Systematic review of the selected 25 articles revealed that FMS patients had higher serum levels of interleukin (IL)-1 receptor antagonist, IL-6, and IL-8, and higher plasma levels of IL-8. Meta-analysis of eligible studies showed that FMS patients had higher plasma IL-6 levels compared to controls (SMD = -0.34 [-0.64, -0.03] 95% CI; p = 0.03). The majority of investigated cytokines were not different between patients and controls. CONCLUSIONS: The pathophysiological role of cytokines in FMS is still unclear. Studies of higher quality and with higher numbers of subjects are needed.

The efficacy of gabapentin (GPT) and pregabalin (PGB) in the treatment of fibromyalgia syndrome (FMS) was assessed. We screened MEDLINE, PsycINFO, SCOPUS, www.clinicaltrials.org, the Cochrane Library (through October 2008), and the reference sections of original studies on GPT/PGB in FMS. Randomized controlled trials (RCTs) on the treatment of FMS with GPT and PGB were analyzed. Six out of 127 RCTs studying 2422 subjects on treatment with GPT (one study) or PGB (five studies) and 1056 subjects on placebo with a median treatment duration of 11 weeks were included into the systematic review. Five studies were suitable for meta-analysis. Effects were summarized using standardized mean differences (SMD). There was strong evidence for a reduction of pain (SMD -0.28, 95% CI -0.36, -0.20; p<0.001), improved sleep (SMD -0.39, 95% CI -0.48, -0.39; p<0.001), and improved health-related quality of life (HRQOL) (SMD -0.30, 95% CI -0.46, -0.15; p<0.001), but not for depressed mood (SMD -0.12, 95% CI -0.30, 0.06; p=0.18). There was strong evidence for a non-substantial reduction of fatigue (SMD -0.16, 95% CI -0.23, -0.09, p<0.001) and of anxiety (SMD -0.18, 95% CI -0.27, -0.10; p<0.001). The external validity of the studies was limited because patients with severe somatic and mental disorders were excluded.

OBJECTIVE: To systematically assess the potential association of fibromyalgia syndrome (FMS) with emotional, physical, and sexual abuse. METHODS: The databases EMBase, Google Scholar, Medline, and PsycINFO (through April 2010) and the reference sections of original studies were searched for eligible studies. Eligible studies were cohort or case--control studies that assessed at least one type of emotional, physical, or sexual abuse in childhood or adulthood in patients with FMS and in controls. Two authors independently extracted descriptive, quality, and outcome data from included studies. Methodologic quality was assessed by the Newcastle-Ottawa Quality Assessment Scale. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were pooled across studies by using the random-effects model. Heterogeneity was assessed by I(2) statistics. RESULTS: The search identified 18 eligible case-control studies with 13,095 subjects. There were significant associations between FMS and self-reported physical abuse in childhood (OR 2.49 [95% CI 1.81-3.42], I(2) = 0%; 9 studies) and adulthood (OR 3.07 [95% CI 1.01-9.39], I(2) = 79%; 3 studies), and sexual abuse in childhood (OR 1.94 [95% CI 1.36-2.75], I(2) = 20%; 10 studies) and adulthood (OR 2.24 [95% CI 1.07-4.70], I(2) = 64%; 4 studies). Study quality was mostly poor. Low study quality was associated with higher effect sizes for sexual abuse in childhood, but not with other effect sizes. CONCLUSION: The association of FMS with physical and sexual abuse could be confirmed, but is confounded by study quality.