Living with Fibromyalgia

Two researchers (Lund I & Lundeberg T) have published an article in the March edition of Acupuncture in medicine : journal of the British Medical Acupuncture Society that discusses pain from a biological and gender perspective.

The researchers noted in their abstract that:

“Pain is a unique personal experience showing variability where gender and sex related effects might contribute. The mechanisms underlying the differences between women and men are currently unknown but are likely to be complex and involving interactions between biological, sociocultural and psychological aspects.”

They say in their article that painful experimental stimuli are generally reported to produce a greater intensity of pain in women than in men, and that clinical pain is often reported with higher severity and frequency, longer duration, and present in a greater number of body regions in women than in men. Women are also more likely to experience a number of painful conditions such as fibromyalgia, temporomandibular dysfunction, migraine, rheumatoid arthritis and irritable bowel syndrome. With Fibro, 80-90% of sufferers are women.

The researchers note that with regard to biological factors, quantitative and qualitative differences in the endogenous pain inhibitory systems have been implicated as possible causes of these differences, as well as an influence of gonadal (sex) hormones. Psychosocial factors like sex role beliefs, pain coping strategies, and pain related expectancies may also contribute to the differences. The researchers also note that “being exposed to repeated painful visceral events [e.g. period pains and childbirth] during life may contribute to an increased sensitivity to, and greater prevalence of, pain among women.”

The researchers concluded that:

“When assessing the outcome of pharmacological and non-pharmacological therapies in pain treatment, the factors of gender and sex should be taken into account as the response to an intervention may differ. Preferably, treatment recommendations should be based on studies using both women and men as the norm. Due to variability in results, findings from animal studies and experiments in healthy subjects should be interpreted with care.”

Other research has suggested that repeated or severe exposure to pain can cause a change in the way the brain works, leading to a lower pain threshold and hypersensitivity to pain. It is one of, or part of, the theories about what causes Fibro – the traumatic trigger event causes the brain to effectively “re-write” how it works. It is an interesting idea that the reason more women get Fibro and other chronic pain conditions may be because women are exposed to much more pain from their own bodies throughout their lives. Possibly in the future, it could lead to options of trying to prevent the onset of Fibromyalgia in girls & women who have been found to have a genetic susceptibility to the condition by aggressively managing period pains and the pain from injuries from puberty onwards. 

An article has been published in the March edition of the journal Arthritis and Rheumatism by a group of researchers including the internationally renowned Fibro expert, Daniel Clauw, which looks at the relationship between Glutamate and Fibro.

The researchers noted that Fibro “is a chronic widespread pain condition that is thought to arise from augmentation of central neural activity” and Glutamate is an excitatory neurotransmitter that functions in pain-processing pathways. The aim of the study was to investigate the relationship between changing levels of Glutamate within the insula (the insular cortex of the brain) and changes in multiple pain domains in patients with Fibro.

For this study, 10 Fibro patients underwent 2 sessions of proton magnetic resonance spectroscopy (H-MRS) and 2 sessions of functional magnetic resonance imaging (fMRI), each being conducted before and after a nonpharmacologic intervention to reduce pain.

During the proton magnetic resonance spectroscopy , the front and back of the insular cortex (the anterior and posterior insular regions) were examined separately using single-voxel spectroscopy, which looks at the image from one point in the 3-D space (one voxel) at a time. The levels of Glutamate and other metabolites were estimated relative to levels of creatine (giving, for example, the Glutamate/Creatine ratio).

During functional magnetic resonance imaging (FMRI), painful pressures were applied to the thumbnail to elicit neuronal activation. Prior to each imaging session, experimental pressure-evoked pain thresholds and clinical pain ratings were also assessed using the Short Form of the McGill Pain Questionnaire [SF-MPQ]) for the clinical pain ratings.

The study found that both experimental pain and SF-MPQ-rated clinical pain were reduced following the non-pharmalogical intervention to reduce pain. Changes from pre- to posttreatment in the Glutamate/Creatine ratio were negatively correlated with changes in experimental pain thresholds and positively correlated with changes in clinical pain. Changes in the fMRI-determined blood oxygenation level-dependent effect (which was used as a measure of neural activation) were positively correlated with changes in the Glutamate/Creatine ratio within the contralateral insula.

The researchers concluded that:

“Changes in [Glutamate] levels within the insula are associated with changes in multiple pain domains in patients with [Fibro]. Thus, H-MRS [proton magnetic resonance spectroscopy] data may serve as a useful biomarker and surrogate end point for clinical trials of [Fibro].”

One day, I hope that PET scans, fMRIs and H-MRS will all be part of the diagnostic process with Fibro and we will be able to move away from the idea that doctors can’t test for it or “see” it.

An article has been e-published ahead of the print in the journal Pain Medicine that discusses the quality of websites on chronic pain.

The researchers from the Department of Anesthesiology at the Dartmouth-Hitchcock Medical Center, New Hampshire, USA said that the “Web not only can play a role in helping patients learn about their chronic pain, but can also be a source of misleading or untrue information. “. Their study aimed to evaluate the quality of Internet information available from different sites concerning chronic pain, and to determine the relationship between the quality of the website’s information and the source and character of the website.

For this study, a survey was carried out of patients seen at the Pain Management Center at Dartmouth-Hitchcock Medical Center (DHMC). Patients who had access to the Internet identified the five most common keywords they used to look up information:

• pain,
• chronic pain,
• back pain,
• arthritis,
• and fibromyalgia.

A focus group of pain clinicians at the DHMC then chose the quality criteria to evaluate websites, which consisted of 16 items in five domains: etiology, diagnosis, goals of treatment, treatment options, and substance abuse. The researchers then assessed the quality of the websites displayed on the first two pages of links from each of three major search engines. A Quality Website Index (QWI) was used to compare results, with a range from -16 (poorest) to +16 (best).

During the study a total of 240 Websites were evaluated, and a mean QWI score of 2.17 was found. The researchers noted that the “overall quality of this group of Websites is rather poor, although there were several excellent sites.” They also found that websites that were located on the main search page had a significantly higher score than those in the sponsored section, and websites based on standards had a significantly higher score than those that were not.

The researchers concluded that:

“Based on QWI scores, clinicians can recommend chronic pain Websites to provide their patients with accurate and pertinent information.”

I guess I’ll pay to see the full article to find out how the QWI of a website is calculated!

The needs assessment that was being done by the Berkshire East PCT has now been extended to cover Berkshire wide. If you live in Berkshire, UK and have had a ME or CFS diagnosis, then please do take the time to fill out the short questionnaire and send it using email or freepost back to the NHS.

The accompanying letter can be found here: Berkshire PCT ME CFS Needs Assessment Letter

The questionnaire can be found here: Berkshire PCT ME CFS Needs Assessment

The definitions used in the questionnaire can be found here: Berkshire PCT ME CFS Needs Assessment Definitions

The voluntary groups who have been campaigning for services for both ME/CFS patients and Fibro patients in Berkshire (the West Berks ME & FM Group, the Reading Area ME Support Group and the Reading & Wokingham Fibromyalgia Support groups) has asked that Fibro be considered in the needs assessment, however this is now definitely not happening. If you live in Berkshire, UK and would like to send a letter to your MP about Fibro being left out of the needs assessment, then you can get a standard letter here that simply needs you to add your name and address. You can find details of who your MP is and where to send the letter here.

To petition your Berkshire MP about the lack of services of people with ME/CFS or Fibro, you can download a petition to be filled in and posted back to the support groups from this page here.

Results of a Korean study announced last year that found changes in unmyelinated nerve cells in Fibro patients have now been published in the journal Clinical Rheumatology. The article ‘Characteristic electron microscopic findings in the skin of patients with fibromyalgia–preliminary study’ is by researchers at Dongguk University College of Medicine in South Korea.

The aim of the blinded study was to determine whether there are any abnormal electron microscopic (EM) findings in the skin of fibromyalgia syndrome (Fibro) patients, which might contribute to or be due to the increased pain sensitivity seen with the condition.

During the study, skin biopsy samples were obtained from 13 Fibro patients and 5 control subjects. Five skin biopsies from healthy controls showed relatively even distribution of variegated sized unmyelinated axons sheathed well by complicatedly folded Schwann cell membranes. In tissues from 9 of the 13 Fibro patients, unmyelinated Schwann cells were noted to be ballooned, whereas this finding was not noted in any controls. Schwann cells are a kind of cell that mainly provide myelin insulation to axons (nerve fibres) in the peripheral nervous system. According to wikipedia “the nervous system relies on this myelin sheath for insulation and as a method of decreasing membrane capacitance in the axon, thus allowing for [nerve] conduction to occur. Non-myelinating Schwann cells are involved in maintenance of axons and are crucial for neuronal survival. “

Axons in most of the Fibro patients trended towards being localized near the edge of the unmyelinated Schwann cell sheaths. This peripheral localization of axons in the unmyelinated Schwann cell sheaths had a strong relationship with the ballooning of the Schwann cells, simplified folding of the Schwann cell sheaths and smaller axons. Myelinated nerve fibers were unremarkable.

Unmyelinated nerve fibres in the peripheral nerves (C fibres) are bundled together by unmyelinating Schwann cells to form Remak bundles of C fiber axons. The free nerve ending of C fibres are pain-sensing nociceptors that respond to all kinds of physiological changes in the body, including  thermal, mechanical, and chemical stimuli. C fibers respond to a stronger intensity of stimulus that the nervers responsible for the sharp first pains and are responsible for the slow, dull, longer-lasting, second pain. C fibers are involved in the process of central sensitisation that can occur after nerve damage causes neuropathic pain.

The researchers concluded that:

“The EM findings seen in the skin of [Fibro] patients show unusual patterns of unmyelinated nerve fibers as well as associated Schwann cells. If these findings are replicated in a larger study, these abnormalities may contribute to, or be due to, the lower pain threshold seen in [Fibro] patients.”

This list of 50 Ways to Help a Chronically Ill Friend comes from my old blog and was inspired by the article ‘50 Ways to Encourage a Chronically Ill Friend’ on the US National Invisible Chronic Illness Awareness Week website.

1. Read the Spoon Theory and send them a link if you think they might not have read it. It can be an amazing encouragement to chronically ill people to know that someone else understand their life.   
   
2. Don’t forget they are sick! Get well cards and gifts dry up pretty quickly when you have a chronic illness, but you don’t get better and unless a hospital stay is needed, it’s easy for everyone to forget that their friend is still ill. If you know that someone with a chronic illness is flaring or is depressed or just because, send them a card or a gift – it’s doesn’t have to be much! Just the thought will make their day.
3. It’s likely that they will be unwilling to ask for help, but will still need it. If you want to help out, try not to ask “What can I do?” which either invites the answer “oh nothing” or means thought is needed. Instead, think of something you would be prepared to do and ask “Is it okay if I do …. for you?”.
4. Be easy going guests if you go visit. Don’t expect entertainment, but also be prepared to do things if wanted. Knowing that a guest isn’t bothered whether we go out for the day (it can be nice to take advantage of having someone there to go places you wouldn’t go alone) or whether they read a book or do the housework is fantastic. It takes the stress away.
5. Preparing food for visitors can be stressful as many chronically ill people will not always eat properly on their own and you can’t suggest crackers for lunch to a guest! Take easily prepared food like fresh bread, dips and cheese/cold meats with you, or pop out to the shops for something. Asking if anything is needed for dinner or offering to pay for a takeaway are also wonderful.
6. If the chronically ill person has a baby, children or even a dog, ask if they would like a break sometimes. You may not even have to take the children/dog out – just having someone prepared to come round and look after them can mean a decent nap or a long bath can be taken.
   
7. If you live locally, easy meals in Tupperware containers dropped off at the house can be a lifesaver…especially if you don’t need the container straight away so it can be frozen. Just make sure you know what they can and cannot eat beforehand! Many chronic illnesses come with dietary restrictions, and these can change with time.
8. Be flexible and never make them feel guilty about things they cannot do. Chronic illnesses do not give schedules of flares or unexpected issues – we do not know in advance how we will be feeling.
9. Ask, “Do you have an errand I can run for you before coming over?”
10. “No matter how little you have, you can always give some of it away.” ~Catherine Marshall. Just listen . . . until it hurts to not say anything. And then listen some more. Chronically ill people usually have a lot to get off their chests and often feel they can’t burden the people around them. Let them know they can talk to you and you’ll listen.
11. If the situation arises, ask “Would you be willing to talk to a friend of mine who has recently been diagnosed with a chronic illness and offer her some encouragement?” It makes one feel good to know that our experience can offer someone else hope and that we still have a purpose in life.
12. Treat them to a gift of movie rentals via postal mail through a service like Amazon rentals. It doesn’t have to cost much and even a few months rental can be a great gift.
    

13. Buy them things to cheer them up after you’ve gone. An inexpensive colourful top, a bright umbrella, a teddy bear or cartoon….
14. Ask them if they’d like to join you for a spontaneous event, whether it’s a local concert, a picnic or just a trip to town. Although it may seem like they cannot go anywhere without lots of planning, if you get them on a good day, then they’ll know then and there they can go!
15. Understand that they live in a constant state of making decisions for which there is no guarantee they are making the right choice.
16. Encourage them to make a (preferably online) wishlist and to add anything they find that could make their lives easier. Financial difficulties often go hand-in-hand with a chronic illness and just because we know of something that could help us, doesn’t mean we can afford it! Then encourage other friends and family to check the wish list for present ideas.
17. Educate yourself. Look up their illness online and if they are having new treatments, try to learn a little about them. It helps to not have to explain every little thing and may well make you understand alot better. Reputable sites like WebMD and Medicinenet are good places to start, but remember that 1, not everything you read will be true, unbiased and completely up-to-date and 2, by the time you have a firm diagnosis, many patients are experts in their own condition(s). Don’t use your knowledge to try and correct the patient – they may simply be more up-to-date with research than whatever you read. Educate yourself and only educate the patient if they ask.
    

18. Research support in their area and then send them no-pressure I-just-heard-about-this-and-thought-you-might-be-interested emails or notes about it. More support is always good, but a lot of the time, chronically ill people may not have the spoons needed to research it. National Associations or Patient Information Points at local hospitals may know of local support groups.
19. Don’t forget the carers. Many chronically ill people are looked after by spouses or parents, even children. Helping the carer means that they can look after the sick person better and the sick person will not feel so guilty that their loved one is their carer. Giving the carer respite breaks, calling them up and asking “how are you doing?” and letting them talk to you frankly or even finding them support (see if they have a local branch of the Princess Royal Trust for Carers , for example) as you might do for the chromically ill person will all help.
20. Be their advocate. If you are at an event and walking/seating is an issue because of their disability, ask if they’d like you to take care of it. If they say you can, be firm but not rude. Don’t embarrass them by making accusations of discrimination or by making a scene.
21. Don’t tell them about your brother’s niece’s cousin’s best friend who tried a cure for the same illness and. . . (you know the rest).
22. Don’t pester them to try something you read or heard about and think might help. If you really think it might help, send them a newspaper cutting and leave it to them to decide whether to follow it up or not.
    

23. Simple acts of kindness like holding the door open (they can be very heavy!) are lovely.
24. Never call them names related to their disability, like “hop-a-long” - at least not until they do it first and then be careful.
25. Never say “maybe you’re not that sick after all”, “it can’t hurt that much”, “you just have a low pain threshold” or minimise or trivialise the symptoms in any way. We get this enough from incompetent doctors when seeking a diagnosis. And far from making much of little aches and pains, most Spoonies are inclined to minimise their symptoms to the outside world – if we are showing pain, then it’s almost certainly a LOT of pain, not us making a fuss over nothing.
26. Temporary illnesses and injuries can help you to understand what a chronically ill person goes through, but it is never the same. We have symptoms that never ever go away and no one without a chronic illness can ever truly understand that. Be careful with simple throw-away phrases like “I know just what you mean” – you probably don’t! If you truly think you get tired or hurt like we do, then there must be something wrong with you!
    

27. If your friend has a disabled parking placard and you are driving, allow them to tell you where they want to park. If they’re feeling particularly good that day, they may not want to park in the “blue space.” Don’t be disappointed that you’ll have to walk farther – it’s a sign of independence and a striving for normality and should be encouraged as long as it’s not done to the point of overdoing things.
28. If you’re going out with a chronically ill friend and they mention they would like to or would normally use a mobility scooter, wheelchair, escalator, lift/elevator, etc don’t complain that it’ll take longer or draw stares. It may be the only way they can go out with you and not make themselves badly ill.
29. Accept that their chronic illness may be lifelong and may not go away. If they’re learning to accept it, don’t tell them the illness is winning and they’re giving in to it. They are simply being realistic!
30. See if there is any way you can enable them to do a loved hobby that their illness restricts. They may be an enthusiastic gardener who can’t dig or move a wheelbarrow or they may be a seamstress who can’t cut a straight line anymore. If by simple acts you can enable them to continue doing something they love, do it! It’ll be better than any gift.
    

31. Never assume they cannot do something without asking. It may be that it is something they can do on a good day and would like to, or that for them it is worth having to spend days resting before and afterwards.
32. Don’t not invite them to things because you don’t think they’ll be able to come. Having a chronic illness is isolating enough without feeling like you’ve been forgotten about completely.
33. Buy them a gift of a favourite magazine subscription. Having a chronic illness can be truly tedious at times, especially as you may not be able to get out to get things like magazines or may not be able to afford them.
34. If they don’t have a cordless phone, it would make a great gift! Comfortable phone headsets or phones with speaker capability make keeping in touch with friends even easier.
35. Ask what time of day is good for calls or visits. They may have a nap schedule they need to keep to or they may know that at certain times of day they’ll feel worse and won’t be up to polite conversation.
36. Be aware that what may seem like minor things to you can be big issues for a chronically ill friend. If you drive somewhere, ask if they’d like to be dropped off while you park. If you go for a picnic or to the beach, be aware that they may not be able to sit on the ground so bring a few folding chairs or cushions so they aren’t the only one perching above their friends. Walking from one shop to another may mean they need a rest before carrying on shopping. Trying to think about these things beforehand and to be accomodating will help alot…they are likely to not want to make a fuss and you helping in small ways can make a huge difference.
    
37. Give them a gift of an attractive plant like a rose bush that could be viewed from a window and say part of the gift is a planting service!
38. Never tease someone about how long they spend in the bathroom…don’t even mention it. If they’re taking a long time or going frequently, it’s because they need to!
39. If they have to stop work or receive disability benefits never say “well, aren’t you lucky. I’d love to sit on the sofa all day and get money for it”. Most chronically ill people would dearly love to be able to work and be independent…and sitting on the sofa soon gets very frustrating if that’s really all you can do.
40. If your friend misses a special event in your life, don’t be grumpy about it. Call and ask if you can bring some photos over and tell them all about it. Let them know that they are still a special person to them and you want them to be part of your life even if they couldn’t be there on the day.
41. If you’re coming for a visit or even just to go out somewhere, call and check it’s still okay before you leave.
42. Always ask before touching or hugging and never give them a power handshake or a friendly biff on the shoulder. Many people with chronic illnesses are in a lot of pain, particularly if they have symptoms like that of Fibromyalgia, where every touch signal can be magnified into significant pain. This changes all the time, so don’t stop hugging them, just check first and be gentle.

    
43. Recognise that pain and extreme tiredness can make anyone irritable (have you never snapped at someone when you’re sick with flu?) and that various medications can affect behaviour. If your friend does or says something rude or hurtful, give them the benefit of the doubt. They may well be horrified afterwards.
44. Make sure they have an answering machine to screen calls when they feel ill…and don’t get offended or call back repeatedly if you get put through to the answering machine!
45. Check that your perfume/aftershave is okay with them. Many people with chronic illnesses end up with chemical sensitivities where some smells can make them physically ill. They may not want to offend you even if you are unconciously making them feel worse!
46. Never smoke around chronically ill people who don’t smoke. As well as chemical sensitivities, they may have breathing issues or the smoke might cause problems with a weak or suppressed immune system.
47. Never criticise someone for taking medications that may be addictive, even if they are ones with bad associations like methadone. Pain relief or illness treatment options can be very limited and it is far better for someone to have medication that makes their life bearable even if it is addictive, than to be in awful pain forever. Recognise that mental and physical addiction such as heroin addicts get is very different to someone needing a drug because without it they can’t get up.
48. Encourage them to research their illness and never tell them it’s making them worse. Self-advocacy in chronically ill patients has been proven to be beneficial to the patients and can be their best hope of gettign a diagnosis, appropriate treatment and coming to terms with their illness.
    
49. If they need to cry, let them and just be there for them. Never say “don’t cry” or “this isn’t worth crying about”…it obviously is to them!
50. And remember that while help is always welcome, do not make a chronically ill person into your personal project – at least not so they notice! Constant suggestions can be stressful in themselves! be subtle and be prepared to take a step back if needed.

Researchers at IMS Health, Brussels and Ghent University, Belgium have published an article in the journal Arthritis and Rheumatism in which they discuss a study evaluating the health economic consequences related to the diagnosis of fibromyalgia syndrome.

People who have worked with the ME community will recognise the name of Simon Wessely amongst the researchers – Dr Wessely is not thought of highly amongst the ME community because of his theories on the psychological basis of ME.

The study aimed to “evaluate the use and costs of medical resources before and after a diagnosis of fibromyalgia syndrome [Fibro] in a large primary care population in the UK.”

The researchers applied an existing data set for medical resource use among patients with a Fibro diagnosis. The patients in the dataset were observed to use 157 types of medical resource and the quantities of these medical resource use, both before and after the Fibro diagnosis, were multiplied by their costs in order to calculate the cost of care within the National Health Service, excluding hospital costs. These costs included general practitioner [GP] visits, drugs, referrals, and diagnostics.

A trend analysis was applied to the costs before diagnosis in order to predict what the later costs would have been if the Fibro diagnosis had never been made. These predicted costs were then compared with the observed costs after diagnosis.

The researchers found that, following a Fibro diagnosis, a decrease in costs was observed, as compared with the predicted costs if the diagnosis had not been made. In the 4 years after diagnosis, the average difference between the observed cost and the predicted cost if the diagnosis had not been made was £66.21 per 6 months per patient. The researchers noted that this “suggests that making the diagnosis leads to savings and a decrease in resource use.”

The main cost saving effect was observed for tests and imaging (£24.02 per 6 months), followed by pharmaceuticals (£22.27), referrals (£5.56), and GP visits (£4.36).

The researchers concluded that:

“Failure to diagnose a true case of FMS has its own costs, largely in excess GP visits, investigations, and prescriptions.”

This study should be used by the NHS to prove the need, in purely financial terms, for better diagnosis of Fibro. However the study, like others before it, does not take into account the number of patients who were given a Fibro diagnosis and then told that there was nothing that could be done for them. I have heard this has happened many times from other patients and it happened to me – all the tests leading up to a rheumatology appointment at which you get given the Fibro diagnosis, maybe told of a few drugs to try if you are lucky, and are then discharged with a statement along the lines of “there is nothing else I can do for you” or “I don’t treat Fibromyalgia”. Not treating Fibromyalgia is obviously a huge cost saving for the NHS and this may actually be a factor in why it is so hard to get specialist services for Fibro from the NHS – the cost of paying for it could cripple the NHS singlehandedly.

I just went on to my old blog to look for an article and it reminded me that it’s a good place to go if someone is looking for a personal journey story with Fibromyalgia, both the downs and the ups - or a history of me taking the dopamine agonists for Fibro. If you want to find out what taking Pramipexole for Fibro can really be like, which is something I have been asked many times, it’s all there, good and bad. The old blog is at http://lindseymiddlemiss.spaces.live.com.

The March Pain-Blog Carnival is now posted at How to Cope with Pain, featuring the month’s best posts. This month there are 10 great posts – I like them all so couldn’t pick any favourites! Check it out here.

Grand Rounds Vol. 4 No. 27 is up at Monash Medical Student. Grand Rounds is a blog carnival showcasing the best of the week’s posts from the medical blogosphere, as chosen by a different host each week. This week’s selection is an in-depth look at the medical blogosphere: I counted 30 posts listed! Here are my favourites:

Dr Schwab at SurgeonsBlog discusses the use of heat treatments in Hot Stuff.

In The Edge Musings of a Distracted Mind posts about two patient encounters, ending the post with: “It is nice to feel liked and important, but you always need to remember that the edge of the cliff may await you in the next exam room.”

Ijeoma Eleazu at Health Observances discusses poly-medicine in Celebrity Drug Overdoses – Who’s Really To Blame. It seems as if poly-medicine which he describes as “using multiple physicians to get medications and not letting one doctor know what the other might be doing by withholding that information” is a gray line away from polypharmacology where one doctor prescribes multiple drugs for the same problem. Polypharmacology is becoming more widely accepted as a good way forward for Fibromyalgia patients, the idea being to try to avoid the side effects of large doses (which people with Fibro seem to be more susceptible to) whilst getting good symptom management by approaching the problem from more than one angle. This post highlights the need for polypharmacology patients to be closely monitored.

The next edition of Grand Rounds will be hosted by GruntDoc.