Discuss the specifics of a physical examination when fibromyalgia is suspected.

1. Arnold LM, Clauw DJ, McCarberg BH; FibroCollaborative. Improving the recognition and diagnosis of fibromyalgia. Mayo Clin Proc. 2011;86(5):457–464....

2. Chakrabarty S, Zoorob R. Fibromyalgia. Am Fam Physician. 2007;76(2):247–254.

3. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33(2):160–172.

4. Katz RS, Wolfe F, Michaud K. Fibromyalgia diagnosis: a comparison of clinical, survey, and American College of Rheumatology criteria. Arthritis Rheum. 2006;54(1):169–176.

5. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010;62(5):600–610.

6. Clauw DJ, Arnold LM, McCarberg BH; FibroCollaborative. The science of fibromyalgia. Mayo Clin Proc. 2011;86(9):907–911.

7. Kim SE, Chang L. Overlap between functional GI disorders and other functional syndromes: what are the underlying mechanisms? Neurogastroenterol Motil. 2012;24(10):895–913.

8. Reed BD, Harlow SD, Sen A, et al. Relationship between vulvodynia and chronic comorbid pain conditions. Obstet Gynecol. 2012;120(1):145–151.

9. Nickel JC, Tripp DA, Pontari M, et al. Interstitial cystitis/painful bladder syndrome and associated medical conditions with an emphasis on irritable bowel syndrome, fibromyalgia and chronic fatigue syndrome. J Urol. 2010;184(4):1358–1363.

10. Smorgick N, Marsh CA, As-Sanie S, Smith YR, Quint EH. Prevalence of pain syndromes, mood conditions, and asthma in adolescents and young women with endometriosis. J Pediatr Adolesc Gynecol. 2013;26(3):171–175.

11. Almansa C, Wang B, Achem SR. Noncardiac chest pain and fibromyalgia. Med Clin North Am. 2010;94(2):275–289.

12. Goldenberg DL. The interface of pain and mood disturbances in the rheumatic diseases. Semin Arthritis Rheum. 2010;40(1):15–31.

13. Häuser W, Galek A, Erbslöh-Möller B, et al. Posttraumatic stress disorder in fibromyalgia syndrome: prevalence, temporal relationship between posttraumatic stress and fibromyalgia symptoms, and impact on clinical outcome. Pain. 2013;154(8):1216–1223.

14. Paras ML, Murad MH, Chen LP, et al. Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis. JAMA. 2009;302(5):550–561.

15. White KP, Nielson WR, Harth M, Ostbye T, Speechley M. Does the label “fibromyalgia” alter health status, function, and health service utilization? A prospective, within-group comparison in a community cohort of adults with chronic widespread pain. Arthritis Rheum. 2002;47(3):260–265.

16. Arnold LM, Clauw DJ, Dunegan LJ, Turk DC; FibroCollaborative. A framework for fibromyalgia management for primary care providers. Mayo Clin Proc. 2012;87(5):488–496.

17. Jones KD, Liptan GL. Exercise interventions in fibromyalgia: clinical applications from the evidence. Rheum Dis Clin North Am. 2009;35(2):373–391.

18. Häuser W, Klose P, Langhorst J, et al. Efficacy of different types of aerobic exercise in fibromyalgia syndrome: a systematic review and meta-analysis of randomised controlled trials. Arthritis Res Ther. 2010;12(3):R79.

19. Brosseau L, Wells GA, Tugwell P, et al. Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1. Phys Ther. 2008;88(7):857–871.

20. Brosseau L, Wells GA, Tugwell P, et al.; Ottawa Panel Members. Ottawa Panel evidence-based clinical practice guidelines for strengthening exercises in the management of fibromyalgia: part 2. Phys Ther. 2008;88(7):873–886.

21. Wang C, Schmid CH, Rones R, et al. A randomized trial of tai chi for fibromyalgia. N Engl J Med. 2010;363(8):743–754.

22. Häuser W, Bernardy K, Uçeyler N, Sommer C. Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis. JAMA. 2009;301(2):198–209.

23. Häuser W, Petzke F, Üçeyler N, Sommer C. Comparative efficacy and acceptability of amitriptyline, duloxetine and milnacipran in fibromyalgia syndrome: a systematic review with meta-analysis. Rheumatology (Oxford). 2011;50(3):532–543.

24. Traynor LM, Thiessen CN, Traynor AP. Pharmacotherapy of fibromyalgia. Am J Health Syst Pharm. 2011;68(14):1307–1319.

25. Tofferi JK, Jackson JL, O'Malley PG. Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Arthritis Rheum. 2004;51(1):9–13.

26. Painter JT, Crofford LJ. Chronic opioid use in fibromyalgia syndrome. J Clin Rheumatol. 2013;19(2):72–77.

27. Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006;174(11):1589–1594.

28. Gaskell H, Moore RA, Derry S, Stannard C. Oxycodone for neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2014;(6):CD010692.

29. Fitzcharles MA, Faregh N, Ste-Marie PA, Shir Y. Opioid use in fibromyalgia is associated with negative health related measures in a prospective cohort study. Pain Res Treat. 2013;2013:898493.

30. Berland D, Rodgers P. Rational use of opioids for management of chronic nonterminal pain. Am Fam Physician. 2012;86(3):252–258.

31. Terry R, Perry R, Ernst E. An overview of systematic reviews of complementary and alternative medicine for fibromyalgia. Clin Rheumatol. 2012;31(1):55–66.

32. De Silva V, El-Metwally A, Ernst E, Lewith G, Macfarlane GJ; Arthritis Research Campaign working group on complementary and alternative medicines. Evidence for the efficacy of complementary and alternative medicines in the management of fibromyalgia: a systematic review. Rheumatology (Oxford). 2010;49(6):1063–1068.


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L.S. is a 70-year-old man with advanced chronic obstructive pulmonary disease. He is intubated and unconscious in the intensive care unit with pneumonia complicated further by acute renal failure. His advance directive, completed seven years ago when he was highly functional, indicates that he wants life-sustaining treatments. He has not updated his advance directive since that time. Members of the medical team are concerned that he has little chance of surviving this hospital stay, and if he were to survive, he is at high risk of significant cognitive deficits that would require long-term skilled nursing care. The patient's wife is listed as his health care agent in his advance directive. She asks how she should proceed with decision making as she struggles to balance what she thinks would be in her husband's best interest and what he has indicated in his advance directive.

Clinicians and surrogates can be faced with challenging decisions when a patient loses the capacity to participate in medical decision making. A significant number of hospitalized and critically ill adults lose decision-making capacity during hospital stays and cannot make treatment decisions.14 A systematic review of the effect of decision making on surrogates found that at least one-third of surrogates experienced significant emotional burden when making medical decisions.5 The most common negative effects cited were stress when making decisions, guilt over the decisions made, and doubt regarding whether they had made the right decisions.5 For some surrogates, the burden of decision making persisted for months or even years.5

In many cases, advance directives can help guide decision making, yet in some cases, directives may be vague or conflict with what clinicians or surrogates view is in the patient's best interest.6  For clinicians, it can be challenging to guide surrogates through the decision-making process while attempting to balance the best interest of the patient and avoiding significant negative emotional impact on the surrogate. Clinicians can strike this balance by (1) knowing the key elements of advance care planning that can be conducted with patients before they lose decision-making capacity and (2) having an approach to medical decision making in place for when patients lose decision-making capacity and their previously expressed wishes appear to conflict with best interest. Key terms for navigating decision making at the end of life are defined in Table 1.79

ADVANCE CARE PLANNING

Advance care planning involves meeting with patients and their surrogates to ensure a shared understanding of diagnosis, prognosis, treatment options, and relevant values and goals, and to establish plans for future treatment that work toward a patient's goals.7 Although the focus of advance care planning is a high-quality conversation rather than just the creation of a static document, the discussion needs to be accurately documented.8 A written advance directive or Physician Orders for Life-Sustaining Treatment (POLST) form can be prepared to document aspects of the advance care planning discussions. Because advance care planning is a dynamic process, these documents should be reviewed and updated accordingly.

One of the most important functions of a written advance directive is designation of a surrogate decision maker. Clinicians can guide patients in choosing an appropriate surrogate who knows the patient well, can make decisions in stressful situations and crises, and makes decisions according to the patient's preferences or best interest rather than his or her own desires.10 Studies have shown that surrogates' predictions of patient preference often mirror their own preferences11; therefore, clinicians can encourage patients to select a surrogate with similar values and preferences.

Once a surrogate has been chosen, it is important for patients to communicate their goals, values, and treatment preferences to this individual. Clinicians can refer patients to a number of decision aids to guide them in this process.12 Encouraging patients to discuss goals, values, and treatment preferences with their surrogate is important to guide decision making in clinical situations that have not been anticipated, previously discussed, or documented in an advance directive form. If the patient chooses to complete a living will outlining specific treatment preferences, the clinician should discuss and document how strictly the patient would like written choices to be followed and how much leeway he or she would like the surrogate to have in decision making.6,11 Knowing how much leeway patients have given their surrogate can help determine what should be done in situations when an advance directive contradicts what appears to be in the best interest of the patient.

WHEN PREVIOUSLY EXPRESSED WISHES CONFLICT WITH BEST INTERESTS

A five-question framework has been proposed to help clinicians determine whether to focus on the patient's previously expressed wishes or on the current best interest of the patient.6

1. Does the urgency of the clinical situation require a time-sensitive decision, are the patient's previously expressed wishes clear, and are POLST documents completed and available? 6 In emergency situations when clear orders are present (e.g., POLST form), the clinician should follow the expressed wishes of the patient. In nonemergency or emergency situations without clear orders, the clinician should determine with the surrogate what would be in the best interest of the patient. In the case of L.S., the clinical situation is urgent yet not emergent and clear orders are not present. This favors a discussion with the patient's wife about the values and experiences that led her husband to choose life-sustaining treatment, which will help determine what would be in his best interest.

2. Considering the patient's preferences and goals of care, are the burdens of the intervention likely to overshadow the benefits? 6 When benefits of an intervention are weak or unlikely, and/or burdens are strong or likely, given the patient's values and goals, the framework recommends against the intervention. When benefits of an intervention are strong and likely, and/or burdens are weak and unlikely, given the patient's values and goals, the framework recommends in favor of the intervention. Discussing L.S.' goals and values with his wife can help determine whether to follow his advance directive or whether his wife should override the document to act in his best interest. If L.S. valued functional independence and had strong preferences about remaining at home rather than in long-term skilled nursing care, the benefits of continued hospitalization would be unlikely and the burdens would be strong. In light of these goals and values, it would be appropriate for L.S.' wife to override her husband's advance directive and make treatment decisions that would honor his preferences.

3. Is the advance directive appropriate in the current situation? 6 In situations where the advance directive fits well, the framework recommends favoring previously expressed orders. In situations where the advance directive fits poorly, the framework recommends favoring the best interest of the patient. L.S.' advance directive may not fit the situation at hand because it was written seven years ago when he was fully functional. This situation favors a discussion with L.S.' wife about what would represent his best interest. Investigating and respecting L.S.' values and goals may be better for approximating what he would choose than previously stated preferences that may have been meant for different circumstances.6

4. How much leeway does the surrogate have to interpret the patient's advance directive? 6 If the patient has not granted the surrogate leeway in decision making, the framework recommends favoring previously expressed orders. If the patient has granted the surrogate leeway in decision making, the framework recommends favoring the best interest of the patient. Some advance directive forms allow patients to specify if they would like their directive to be followed strictly or to serve as a general guide for their surrogate. When leeway is not indicated, what is known about the patient's previous values and goals needs to provide a compelling reason to modify directives.6 In L.S.' case, there was no indication of his leeway preferences, and his advance directive is vague; therefore, it would be appropriate for the clinician to investigate L.S.' goals and values with his wife to determine appropriate recommendations.

5. Is the surrogate acting in the patient's best interests? 6 When the surrogate represents the patient's best interest poorly or represents his or her own interest, the framework recommends favoring previously expressed orders. When the surrogate represents the patient's best interest, the framework recommends favoring the best interest of the patient. In some cases, surrogates' emotional attachment may be so strong that they are unable to place the patient's best interest above their own.6 If L.S.' wife stated that she could not let her husband go, the clinician would first need to address her emotions and anticipatory grief before talking with her to determine what would be in her husband's best interest.6 The authors of this framework also encourage clinicians to recognize possible conflicts of interest, such as the surrogate's expressed desire to receive a pension or inheritance. To mitigate bias that may stem from these situations, they advise the clinician to consult with an ethics expert or contact adult protective services.6


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Am Fam Physician. 2015 Apr 1;91(7):487-488.

A 26-year-old man presented with a four-year history of exophytic growths on his back and extensive scarring on his chest. The lesions were flesh colored, nontender, and progressively worsening. His medical history was significant for moderate to severe acne, which required treatment with oral isotretinoin. The lesions gradually developed, extending beyond the borders of inflammatory acne cysts. They significantly affected his appearance and caused severe distress.

Physical examination revealed multiple oval and round, hypertrophic, nodular tumors on his back (Figure 1). They ranged in size from 2 to 10 cm. On the anterior chest, there were multiple areas of hypertrophic scars (Figure 2).

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Cutaneous T-cell lymphoma (mycosis fungoides tumors).

B. Lepromatous leprosy.

C. Lobomycosis.

D. Neurofibromatosis 1.

E. Postacne keloids.

The correct answer is E: postacne keloids. Keloids are common, benign, flesh-colored dermal tumors that occur during the process of wound healing. They are characterized by excess deposition of collagen and have varying degrees of clinical severity. Keloids and hypertrophic scars are a variation of normal wound healing. Keloids extend beyond the borders of the original trauma and do not spontaneously regress, whereas hypertrophic scars are confined to the borders of the inciting injury, retaining its shape.1 Both can develop after trauma to the deep dermis.

There is no standardized evidence-based treatment for keloids. Preventing them by avoiding unnecessary surgery in patients who are prone to keloids is the most effective approach. Treatment modalities offer minimal improvement, and lesions can recur. This patient was treated unsuccessfully with topical imiquimod (Aldara), cryosurgery in combination with intralesional corticosteroid injections, and excisional surgery.

Cutaneous T-cell lymphoma is a type of non-Hodgkin lymphoma characterized by the presence of neoplastic T lymphocytes in the skin. The two most common types are mycosis fungoides and Sézary syndrome.2 Mycosis fungoides has three stages: patch (atrophic or nonatrophic), plaque, and tumor. The tumors are red, purple, or brown nodules with a smooth surface. They are dome shaped and exophytic, and have a predilection for the face and body folds. The growth rate varies, and they may become ulcerated.

Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae. In lepromatous leprosy, there is a lack of cell-mediated immunity toward M. leprae, which allows dissemination of the infection. Early cutaneous lesions are pale macules with little or no loss of sensation. Later lesions (lepromas) are poorly defined, symmetrically distributed, flesh-colored nodules.3 Leonine facies, a deeply furrowed face with thickened skin, is a classic presentation in leprosy. There is no clinical inflammation. Loss of eyebrow hair is common.

Lobomycosis, also known as Lobo disease or lacaziosis, is a chronic, self-limited, cutaneous fungal infection. It was first reported as keloidal blastomycosis4 and is endemic in rural regions of South and Central America. It is characterized by slow-growing, keloid-like lesions on exposed skin accompanied by pruritus or a burning sensation. The lesions may begin as small papules, plaques, or pustules at sites of minor trauma.5

Neurofibromatosis 1, or von Recklinghausen disease, is an autosomal dominant condition that accounts for 90% of neurofibromatosis cases.6 It is characterized by peripheral or central nervous system neoplasms, pigmented iris hamartomas (Lisch nodules), and various skin lesions such as multiple neurofibromas, café au lait spots, and axillary and inguinal freckling.


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Am Fam Physician. 2015 Apr 1;91(7):490.

What is the effect of treatment for cervical intraepithelial neoplasia (CIN) on fertility and early pregnancy outcomes?

In this analysis of 15 observational studies (it would be difficult and unethical to do randomized research on this topic), excision using any method for CIN did not affect fertility, although second trimester miscarriages were more likely. A study published at the same time found the risk of preterm birth doubled with excisions of a depth of at least 15 mm. (Level of Evidence = 2a)

To conduct this meta-analysis, the authors used Medline and Embase to identify all studies that compared fertility and early pregnancy (< 24 weeks' gestation) outcomes in women with or without treatment for CIN. They included all types of treatment, both ablative and excisional. Two investigators independently performed the literature searches and data extraction. The authors included 15 cohort studies that used any method to assemble women who did and did not undergo treatment, and evaluated fertility and early pregnancy outcomes. Regardless of type of treatment, pregnancy rates or time to conception in women trying to conceive was not affected by treatment of CIN in four studies of 38,050 women. Total miscarriage rates also were not different in 10 studies of 39,504 women. However, second semester miscarriage rates were higher (1.6% vs. 0.4%) in women who underwent treatment (risk ratio = 2.60; 95% confidence interval, 1.45 to 4.67). The numbers of ectopic pregnancies (1.6% vs. 0.8%) and pregnancy terminations (12.2% vs. 7.4%) were also higher in treated women. In a separate case-control study that evaluated 1,313 women who underwent colposcopy with 1,313 matched control patients, the risk of preterm birth was not affected by a small excision, but larger lesions (15 mm or more) were associated with a doubling of the risk of preterm and very preterm births, independent of the time since the excision (BMJ. 2014;349:g6223).

Study design: Meta-analysis

Funding source: Government

Setting: Various (meta-analysis)

Reference: Kyrgiou M, Mitra A, Arbyn M, et al. Fertility and early pregnancy outcomes after treatment for cervical intraepithelial neoplasia: systematic review and meta-analysis. BMJ.. 2014; 349: g6192.

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This series is coordinated by Sumi Sexton, MD, Associate Medical Editor.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.