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Background Chronic prostatitis has been a common disease reported with high frequency in ankylosing spondylitis (AS) even from decades ago. Infectious (Chlamydia trachomatis) or non-infectious (uric acid) prostatitis can hypothetically trigger vertebral inflammation in AS. This study aimed to assess the features of chronic prostatitis in patients with AS compared to healthy controls. Methods A cross-sectional study including male patients with AS and healthy controls who agreed to undergo a prostate examination was conducted. Structured clinical interviews, prostate physical examinations, and cytological, biochemical, and microbiological tests on urinary samples collected before and after standardized prostatic massage (pre- and post-massage test) were performed. Results Ninety participants (45 AS patients, mean age: 52.5 ± 10.0 years, with longstanding disease, 12.4 ± 6.9 years, and 45 controls, mean age: 52.8 ± 12.1 years) were included. National Institutes of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) scores were similar in the AS and control groups (4.0 [1.0–12.0] vs. 5.0 [1.0–8.5], p = 0.994). The frequencies of symptoms of chronic prostatitis (NIH-CPSI Pain Domain ≥4) were also similar in both groups (23.3% vs. 22.7%, p = 0.953). Results of polymerase chain reaction tests for Chlamydia trachomatis were negative in all tested urinary samples, and uric acid concentrations and leukocyte counts were similar in all pre- and post-massage urinary samples. Conclusions In this study, chronic prostatitis occurred in male patients with AS, but its frequency and characteristics did not differ from those found in the healthy male population of similar age.

Resumo Objetivo Avaliar os parâmetros associados a qualidade de vida em pacientes com doenca de Paget ossea (DPO). Metodos Avaliaram‐se pacientes com DPO com os questionarios SF‐36 e WHOQOL‐bref. Excluiram‐se pacientes com outras doencas que pudessem causar comprometimento significativo da qualidade de vida. Buscou‐se por correlacoes entre os resultados e idade, tempo de diagnostico, tipo de envolvimento, dor relacionada com a DPO, limitacao as atividades diarias, deformidades, fosfatase alcalina especifica do osso, extensao do envolvimento e tratamento. Resultados Incluiram‐se 50 pacientes. Os resultados da pontuacao total do SF‐36 e seus dominios, saude fisica e saude mental, se correlacionaram significativamente com a dor ossea e deformidades. O estado civil se correlacionou significativamente com a pontuacao total do SF‐36 e com seu dominio saude mental. Os niveis de BAP e a extensao da doenca se correlacionaram significativamente com o dominio saude fisica do SF‐36. Depois da analise multivariada, os unicos parâmetros que permaneceram significativamente associados a pontuacao total do SF‐36 e aos seus dominios saude mental e saude fisica foram a dor e o estado civil. A pontuacao total do WHOQOL‐bref esteve significativamente associada a dor, ao comprometimento fisico e a deformidades. O escore do Dominio 1 (fisico) do WHOQOL‐bref esteve significativamente associado ao estado civil, dor e deformidades, enquanto o Dominio 2 (psicologico) esteve associado ao estado civil, comprometimento fisico e tipo de envolvimento. Depois da analise multivariada, a presenca de dor, deformidades e estado civil esteve significativamente associada a pontuacao total do WHOQOL‐bref e a pontuacao do seu Dominio 1. Os resultados do WHOQOL‐bref 2 foram significativamente preditos pela dor e pelo estado civil. Conclusao O principal fator associado aos escores do SF‐36 foi a dor ossea, enquanto a dor ossea e as deformidades estiveram associadas ao WHOQOL‐bref.

ResumoObjetivoEste estudo teve como objetivo analisar a relação entre o polimorfismo do gene PDCD1 (programmed cell death 1) (PD1.3G/A ‐ rs11568821) com características do lúpus eritematoso sistêmico (LES) e da artrite reumatoide (AR) em uma população do sul do Brasil.MétodosA técnica de PCR‐RFLP (Polymerase Chain Reaction‐Restriction Fragment Lenght Polymorphism) foi utilizada para analisar amostras de 95 pacientes com LES e 87 com AR, assim como em 128 indivíduos do grupo controle de Santa Catarina, sul do Brasil. Foi analisada a probabilidade de equilíbrio de Hardy‐Weinberg (EHW) e a odds ratio (OR), considerando um IC 95% e p ≤ 0,05.ResultadosAs frequências alélicas PD1.3A foram de 0,095 (LES), 0,115 (AR) e 0,078 (controles). Os genótipos do grupo controle estavam em EHW, enquanto aqueles dos pacientes com LES e AR não estavam. No entanto, não foi encontrada associação entre o polimorfismo PD1.3 e a suscetibilidade ao LES ou à AR, nem com dados clínicos ou epidemiológicos.ConclusãoNão foi encontrada associação significativa entre o polimorfismo PD1.3 e a susceptibilidade ao LES ou à AR nessa população do sul do Brasil.AbstractObjectiveThis study aims to analyze the relationship of programmed cell death 1 (PDCD1) gene polymorphism (PD1.3G/A ‐ rs11568821) with features of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) in a Southern Brazilian population.MethodsPolymerase Chain Reaction–Restriction Fragment Length Polymorphism (PCR‐RFLP) was performed in 95 SLE and 87 RA patients and 128 control group individuals from Santa Catarina, Southern Brazil. The Hardy‐Weinberg Equilibrium (HWE) test, and odds ratio (OR) were analyzed, considering CI 95% and p≤0.05.ResultsThe PD1.3A allele frequencies were 0.095 (SLE), 0.115 (RA) and 0.078 (controls). The genotypes of the control group were in HWE, while those of SLE and RA patients were not. However, we found no association between PD1.3 polymorphism and the SLE or RA susceptibility, nor clinical or epidemiological data.ConclusionThere was no significant association between PD1.3 polymorphism and SLE or RA susceptibility in this Southern Brazilian population.

Objective: This study aims to analyze the relationship of programmed cell death 1 (PDCD1) gene polymorphism (PD1.3G/A - rs11568821) with features of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) in a Southern Brazilian population. Methods: Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was performed in 95 SLE and 87 RA patients and 128 control group individuals from Santa Catarina, Southern Brazil. The Hardy-Weinberg equilibrium (HWE) test, and odds ratio (OR) were analyzed, considering CI 95% and p ≤ 0.05. Results: The PD1.3A allele frequencies were 0.095 (SLE), 0.115 (RA) and 0.078 (controls). The genotypes of the control group were in HWE, while those of SLE and RA patients were not. However, we found no association between PD1.3 polymorphism and the SLE or RA susceptibility, nor clinical or epidemiological data. Conclusion: There was no significant association between PD1.3 polymorphism and SLE or RA susceptibility in this Southern Brazilian population. RESUMO Objetivo: Este estudo teve como objetivo analisar a relação entre o polimorfismo do gene PDCD1 (programmed cell death 1) (PD1.3G/A - rs11568821) com características do lúpus eritematoso sistêmico (LES) e da artrite reumatoide (AR) em uma população do sul do Brasil. Métodos: A técnica de PCR-RFLP (Polymerase Chain Reaction-Restriction Fragment Lenght Polymorphism) foi utilizada para analisar amostras de 95 pacientes com LES e 87 com AR, assim como em 128 indivíduos do grupo controle de Santa Catarina, sul do Brasil. Foi analisada a probabilidade de equilíbrio de Hardy-Weinberg (EHW) e a odds ratio (OR), considerando um IC 95% e p ≤ 0,05. Resultados: As frequências alélicas PD1.3 A foram de 0,095 (LES), 0,115 (AR) e 0,078 (controles). Os genótipos do grupo controle estavam em EHW, enquanto aqueles dos pacientes com LES e AR não estavam. No entanto, não foi encontrada associação entre o polimorfismo PD1.3 e a suscetibilidade ao LES ou à AR, nem com dados clínicos ou epidemiológicos. Conclusão: Não foi encontrada associação significativa entre o polimorfismo PD1.3 e a susceptibilidade ao LES ou à AR nessa população do sul do Brasil.

OBJETIVOS: Avaliar a prevalência de aterosclerose subclínica em pacientes com espondilite anquilosante (EA) em comparação com controles com fatores de risco cardiovasculares similares. MÉTODOS: Foram recrutados 42 pacientes consecutivos com EA e 42 controles equiparados para idade (43,3 ± 11,7 vs. 43,7 ± 11,3, P = 0,89), gênero, tabagismo, diabetes mellitus e hipertensão arterial. Qualquer participante seria excluído se estivesse presente uma história pessoal de doença cardiovascular (CV). Foi preenchido um questionário registrando dados demográficos e histórias médica e de medicação. Foram determinados: pressão arterial, circunferência abdominal, altura e peso. O perfil lipídico foi determinado em uma amostra de sangue com 12 horas em jejum. Foi realizada uma análise ultrassonográfica da artéria carótida comum por um observador desconhecedor da pesquisa. Foi medida a distância entre a interface lúmen-íntima e a borda de ataque da interface média-adventícia (EIM) e os participantes também foram avaliados para presença de placas. RESULTADOS: A análise comparativa dos fatores de risco demográficos e cardiovasculares entre pacientes com EA e controles não revelou diferenças estatisticamente significativas. Também não foram observadas diferenças significativas entre grupos para TC, HDL-C, T-C/ HDL-C, LDL-C, triglicerídeos ou frequência de dislipidemia. As medidas de EIM não foram diferentes em EA e controles (0,62 ± 0,09 vs. 0,61 ± 0,09, P = 0,39) e nem as frequências de placas (19% vs. 17%, P = 0,78). CONCLUSÕES: A aterosclerose subclínica avaliada por meio de imagens ultrassonográficas da carótida não foi mais prevalente no grupo EA, em comparação com os controles com riscos cardiovasculares similares. Nossas observações podem implicar que os fatores de risco CV podem ter mais influência no sistema CV versus a própria EA. Esses achados devem ser confirmados em uma população maior, por meio de um estudo prospectivo. OBJECTIVES: To evaluate the prevalence of subclinical atherosclerosis in patients with ankylosing spondylitis (AS) in comparison to controls with similar cardiovascular risk factors. METHODS: Forty-two consecutive patients with AS and 42 controls matched for age (43.3 ± 11.7 vs. 43.7 ± 11.3, P = 0.89), gender, smoking, diabetes mellitus and arterial hypertension were enrolled. Participants were excluded if a personal cardiovascular disease (CV) history was present. A questionnaire recording demographic data, medical and medication history was fulfilled. Blood pressure, abdominal circumference, height and weight were measured. Lipid profile was determined in a 12-hour fastened blood sample. Ultrasound analysis of the common carotid artery was performed by one blind observer. The distance between the lumen-intima interface and the leading edge of the media-adventitia interface (IMT) was measured and participants were also evaluated for the presence of plaques. RESULTS: The comparative analysis of demographic and cardiovascular risk factors between AS patients and controls did not reveal statistically significant differences. Also, no significant differences between groups were observed for TC, HDL-C, T-C/HDL-C, LDL-C, triglycerides, or dyslipidemia frequency. IMT measures were not different in AS and controls (0.62 ± 0.09 vs. 0.61 ± 0.09, P = 0.39) as well as plaques frequencies (19% vs. 17%, P = 0.78). CONCLUSIONS: Subclinical atherosclerosis assessed through carotid ultrasound imaging was not more prevalent in the AS group when compared to controls with similar cardiovascular risks. Our observations may imply that CV risk factors may have more influence on the CV system than AS itself. These findings should be confirmed in a larger population with a prospective study design.

Description of the method to elaborate the evidenceThe members of the Comissão de Esclerose Sistêmica da Sociedade Brasileira de Reumatologia (Systemic Sclerosis Commission of the Brazilian Society of Rheumatology, SBR) 2010- 2012 took part in the Evidence Preparation Course given by the Associação Médica Brasileira (Brazilian Medical Association, AMB) in São Paulo in the first semester of 2011. The questions were formulated and discussed via internet in the second semester of 2011. The 15 clinical questions considered to be relevant were structured using the P.I.C.O. method (patient; intervention or indicator; comparison; outcome). The literature search was conducted by searching the databases MEDLINE, EMBASE, SciElo/Lilacs, and the Cochrane Library through February, 2012 (Appendix). Critical assessment of the evidence in the selected articles was performed using the Jadad score. The observational studies and case series were considered for analysis when randomised clinical trials could not be located. A manual search located the relevant studies that were included in the analysis. The answers to the questions included in the Recommendations were refined and elaborated, and all of the selected references exhibited the corresponding grade of recommendation and the strength of scientific evidence. The references were updated through December, 2012, entered into a single file by the coordinator, and sent to the co-authors in four successive rounds for preparation of the final version.Grades of recommendation and strength of evidenceA.Most consistent experimental and observational studies.B.Less consistent experimental and observational studies.C.Case reports (uncontrolled studies).D.Opinion that is not substantiated by critical evaluation, based on consensus, physiological studies or animal models.ObjectiveTo establish recommendations for the management and treatment of systemic sclerosis.

Objective To assess the association of the polymorphisms of the interleukin-18 (IL-18) gene with rheumatoid arthritis (RA) and with risk factors for cardiovascular diseases (CVD). Methods This sample comprised 97 patients with RA and 151 healthy controls. In the patients, risk factors for CVD were analyzed, such as cholesterol levels, arterial hypertension, smoking habit, C-reactive protein (CRP) level, and rheumatoid factor. DNA was extracted and the single nucleotide polymorphisms (SNP) at the -607C/A and -137G/C positions of the IL-18 gene were assessed in both groups. The Hardy-Weinberg equilibrium (HWE) was calculated and the odds ratio (OR) test performed, considering a 95% CI and P Results The frequencies of the -607A allele in patients with RA and in controls were 0.443 and 0.424, respectively, and of the -137C allele, 0.304 and 0.291, respectively. The genotype frequencies were in HWE, except for controls in the -137 locus (P = 0.006). Association of the polymorphisms of the IL-18 gene was found with neither RA nor risk factors for CVD, including cholesterol level and CRP (P > 0.05). In addition, more smokers were found among patients with RA as compared with controls (OR = 1.691; P = 0.088), and the CRP levels were slightly higher in patients who smoked than in patients who did not (OR = 2.673; P = 0.061). Conclusions In this sample of patients with RA in the South of Brazil, association of the polymorphisms of the IL-18 gene was observed with neither RA nor risk factors for CVD.

Calcification and ossification of the ligamentum flavum or of the posterior longitudinal ligament are causes of compressive myelopathy, more frequent in the lower thoracic levels, and extremely rare in Western populations. Surgical decompression is the only therapy, but the disease is usually progressive, and its recurrence after surgery is common. Inflammatory mediators might play a role in the progression of compressive myelopathy, but, to our knowledge, the therapeutic approach involving anti-inflammatory agents has never been tried before. We report a case of compressive myelopathy due to calcification of the ligamentum flavum, in which hyperproteinorachia and response to steroid therapy have been observed. Those data have not been published before and might provide new ideas for the disease understanding.

Aim: To investigate serum levels of tumor markers in patients with rheumatoid arthritis (RA) and their association with disease activity or the presence of cancer. Method: We performed an observational cohort study including 100 patients with RA and control subjects. Serum levels of tumor markers carcinoembryonic antigen (CEA), cancer antigen (CA) 125, CA 19–9 and CA 15–3 were evaluated along with clinical and laboratorial RA data. Association tests between tumor markers levels and RA disease activity parameters were performed. Patients with abnormal tests were submitted to further investigation, including chest X-ray, colonoscopy, abdominal ultrasonography, upper gastrointestinal endoscopy and mammography, depending on the type of tumor marker that was elevated. Results: Patients with RA had high levels of CEA and CA 19–9 more frequently than controls (P < 0.05). No correlation was found between tumor markers and RA disease activity assessed by the Disease Activity Score 28. Two neoplasms were found, but only one was related to high tumor marker (an ovarian carcinoma with high CA 125 levels).

OBJETIVO: As condições musculoesqueléticas possuem um enorme e crescente impacto no mundo. A despeito disso, alguns médicos não estão confiantes em suas próprias habilidades para a realização do exame clínico musculoesquelético. Este estudo teve como objetivo avaliar a prevalência dos sintomas musculoesqueléticos em uma unidade de emergência e a frequência de descrição do exame físico musculoesquelético nesses casos. MÉTODOS: Trata-se de estudo transversal. Foi realizada uma análise sistemática das fichas de atendimento na unidade de emergência do hospital da Universidade Federal de Santa Catarina, Brasil, de 24 a 30 de abril de 2009. RESULTADOS:Foram analisadas 392 fichas de atendimento, onde 41,5% dos pacientes eram do sexo masculino e a idade média de 38,7 ± 17,2 anos. Sessenta e nove dos 392 pacientes (17,6%) apresentaram-se com queixa musculoesquelética. A queixa musculoesquelética mais comum foi lombalgia (33/69). Somente 49,2% dos pacientes que apresentavam distúrbios musculoesqueléticos como queixa principal tiveram exame físico específico descrito nas fichas. Pacientes com queixas musculoesqueléticas tiveram menor frequência de registro de exame abdominal (46% versus 62%, P = 0,01) e sinais vitais (46% versus 66%, P = 0,00), porém maior frequência de registro do exame musculoesquelético (49% versus 0,6%, P = 0,00). CONCLUSÕES:Este estudo confirma outras observações em todo o mundo. Queixas musculoesqueléticas são frequentes em uma unidade de emergência e, apesar disso, sugere-se que os sintomas musculoesqueléticos são insuficientemente avaliados, o que pode estar relacionado a uma educação médica insuficiente. É fundamental que escolas médicas coloquem maior ênfase nessas condições para que jovens médicos estejam mais preparados para lidar com essas doenças comuns. OBJECTIVE: Musculoskeletal conditions have an enormous and growing impact worldwide. In spite of that, some clinicians are not confident in their own musculoskeletal examination skills. This study aimed to evaluate the prevalence of musculoskeletal symptoms in an emergency room, and the frequency of musculoskeletal physical examination description on those cases. METHODS: This was a cross-sectional study. We performed a systematic analysis of medical files at the emergency room of the University Hospital of the Federal University of Santa Catarina, Brazil, from April 24th to 30th, 2009. RESULTS: We analyzed 392 files, where 41.5% of patients were male and mean age was 38.7 ± 17.2 years-old. Sixty nine out of 392 patients (17.6%) presented with a musculoskeletal complaint. The most common musculoskeletal complaint was low back pain (33/69). Only 49.2% of patients with a musculoskeletal chief complaint had a specific physical examination registered on the files. Patients with musculoskeletal complaints had lower registrations of abdominal examination (46% versus 62%, P = 0.01) and vital signs (46% versus 66%, P = 0.002), but a higher frequency of musculoskeletal examination registration (49% versus 0.6%, P = 0.00). CONCLUSIONS: Our study confirms other observations worldwide. Musculoskeletal complaints are frequent in a emergency room setting and in spite of that it is suggested that musculoskeletal symptoms are poorly evaluated, which is probably related to an insufficient musculoskeletal education. It is essential that medical schools place more emphasis on these conditions so that young physicians will be more prepared to deal with these common diseases.

Resume Objectifs Etudier le profil lipoproteique de patients atteints du syndrome de Sjogren primaire (SSp) et son association avec des parametres biologiques, y compris les marqueurs de l’inflammation. Methodes Nous avons realise une etude transversale chez des patients atteints de SSp et de temoins sains. Nous avons analyse le profil lipoproteique de 73 patients atteints de SSp et les avons compare a celui de 65 temoins sains. Nous avons evalue les associations eventuelles entre une dyslipidemie chez les patients atteints de SSp et les parametres biologiques, y compris : hypergammaglobulinemie, autoanticorps (anticorps antinucleaires [ANA], facteur rhumatoide [FR], anti-Ro, anti-La) et reactifs de la phase aigue (proteine C-reactive [CRP] et vitesse de sedimentation [VS]). Resultats Les variables demographiques etaient comparables chez les patients et les temoins. Les profils lipoproteiques etaient comparables chez les patients atteints de SSp et les temoins : cholesterol total (204,0 ± 43,39 versus 206,5 ± 42,76 mg/mL, p = 0,73), fraction LDL (131,6 ± 37,38 versus 130,62 ± 38,24 mg/dL, p = 0,88), fraction HDL (49,7 ± 13,5 versus 51 ± 11,5 mg/dL, p = 0,56) et triglycerides (129,3 ± 81,0 versus 116,8 ± 53,5 mg/dL, p = 0,29). Toutefois, les patients atteints de SSp presentaient plus frequemment une dyslipidemie que les sujets sains (76,7 % versus 61,5 %, p = 0,06). La presence de dyslipidemie chez les patients atteints de SSp etait associee a une augmentation de la VS (44,05 ± 28,07 versus 28,28 ± 18,00, p = 0,03), mais pas a d’autres marqueurs biologiques de la maladie et de l’inflammation. Discussion/conclusion Les patients atteints du SSp presentent souvent un profil lipidique anormal, associe a une VS elevee. Ainsi, comme pour d’autres maladies inflammatoires systemiques tels que la polyarthrite rhumatoide (PR) et le lupus erythemateux systemique (LES), le profil lipidique devrait etre evalue chez les patients atteints de SSp, afin d’initier une strategie therapeutique specifique pour la prevention des evenements cardiovasculaires.

O objetivo deste estudo é descrever as características clínicas e as respostas às intervenções terapêuticas, incluindo a terapia antifator de necrose tumoral (TNF), em uma série de casos brasileiros de arterite de Takayasu (AT). Foi realizado um estudo observacional, retrospectivo, com base na revisão de prontuários, incluindo todos os pacientes com AT, de acordo com os critérios de classificação do American College of Rheumatology, em acompanhamento no Serviço de Reumatologia do Hospital Universitário da Universidade Federal de Santa Catarina (UFSC), Brasil. Foram incluídos 15 pacientes, sendo 14 (93,3%) mulheres, com idade média ao diagnóstico de 29,6 anos. Hipertensão arterial sistêmica (60,0%) e ausência de pulsos em membros superiores (53,3%) foram os achados clínicos mais comuns ao diagnóstico. As artérias subclávias e carotídeas foram os vasos mais frequentemente acometidos. Doze pacientes (80,0%) não obtiveram remissão sustentada em terapia isolada com corticosteroide, tendo sido empregada terapia imunossupressora, sendo metotrexato, azatioprina e ciclofosfamida as drogas utilizadas. Intervenções cirúrgicas foram necessárias em 53,3% dos casos. Três casos (20,0%) foram refratários à terapia com corticoides e imunossupressores e foram tratados com agentes anti-TNF, com subsequente remissão da doença. Em conclusão, observou-se que uma parcela importante dos casos de AT é refratária à terapia tradicional e os agentes anti-TNF podem representar uma opção promissora para o controle da doença nesses casos. The aim of this study was to describe clinical features and response to different therapeutic interventions, including anti-tumor necrosis factor (TNF) agents, in a case series of Takayasu arteritis (TA) from Brazil. A retrospective observational chart-review study was performed including all patients meeting the American College of Rheumatology TA classification criteria followed at the rheumatology outpatient clinic of a Brazilian university hospital. Fifteen patients were included, of which 14 (93.3%) were females, with a mean age of 29.6 years at diagnosis. Systemic hypertension (60.0%) and abolished upper limb pulses (53.3%) were the most common clinical features at the diagnosis. Subclavian and carotid arteries were the most commonly affected vessels. Twelve patients (80.0%) did not achieve sustained remission on therapy with corticosteroids alone and received immunosuppressive agents including methotrexate, azathioprine and cyclophosphamide. Surgical intervention was necessary and performed in 53.3% of cases. Three cases (20.0%) were refractory to corticosteroid plus diverse immunosuppressive therapy and were treated with anti-TNF agents, all of them with disease remission. In conclusion, a significant proportion of TA cases are refractory to traditional therapy. The use of anti-TNF agents may become a possible therapy for these patients.

Spondyloarthritis (SpA) is a musculoskeletal inflammatory disease linked with immune responses to intestinal microbiota, and subclinical intestinal ulcerations that are closely related to inflammatory bowel diseases. Helicobacter pylori is a common cause of gastroduodenal ulceration, and anti-Saccharomyces cerevisiae antibodies (ASCA) are associated with intestinal inflammation in both Crohn disease (CD) and SpA. We investigated the relationship between H. pylori and ASCA. Ninety-one patients with axial SpA and forty with CD were included. ASCA IgG/IgA and anti-H. pylori IgG titers were assessed by ELISA. The proportion of ASCA+ patients in the positive and negative anti-H. pylori IgG groups with SpA and CD were compared using Chi-square tests, and correlations were evaluated using the Spearman’s coefficient. Anti-H. pylori IgG titers were significantly negatively correlated with the ASCA IgG (r = −0.563, p

Descricao do metodo de elaboracao das evidencias Os integrantes da Comissao de Esclerose Sistemica da Sociedade Brasileira de Reumatologia (bienio 2010-2012) participaram do Curso de Elaboracao de Evidencias da Associacao Medica Brasileira, em Sao Paulo, durante o primeiro semestre de 2011. As questoes foram propostas e discutidas pela internet, no segundo semestre de 2011. As 15 questoes clinicas consideradas relevantes foram estruturadas por meio da estrategia do P.I.C.O. (Paciente; Intervencao ou Indicador; Comparacao; Outcome). As estrategias de busca avaliaram as bases de dados MEDLINE, EMBASE, Scielo/Lilacs, Cochrane Library ate setembro de 2012 (Apendice). Os artigos selecionados na primeira estrategia de busca foram submetidos a avaliacao critica das evidencias, utilizando-se o escore de Jadad. Foram considerados tambem estudos observacionais e series de casos na ausencia de ensaios clinicos randomizados. Foi realizada insercao de estudos relevantes obtidos por busca manual. Posteriormente, foram elaboradas as respostas as perguntas das Recomendacoes, em que cada referencia bibliografica selecionada apresentava o correspondente grau de recomendacao e forca de evidencia cientifica. Para as Recomendacoes finais, as referencias bibliograficas foram atualizadas ate dezembro de 2012, redigidas em texto unico pelo coordenador, e submetidas aos coautores em quatro turnos, para elaboracao do texto final. Grau de recomendacao e forca de evidencia A: Estudos experimentais e observacionais de melhor consistencia. B: Estudos experimentais e observacionais de menor consistencia. C: Relatos de casos (estudos nao controlados). D: Opiniao desprovida de avaliacao critica, baseada em consensos, estudos fisiologicos ou modelos animais. Objetivo Estabelecer as recomendacoes para o manejo e para o tratamento da esclerose sistemica.

OBJETIVO: Analisar a associação dos polimorfismos do gene interleucina-18 (IL-18) com artrite reumatoide (AR) e com fatores de risco de doenças cardiovasculares (DCV). MÉTODOS: A amostra foi constituída por 97 pacientes com AR e 151 controles saudáveis. Nos primeiros, foram analisados fatores de risco de DCV, tais como níveis do colesterol, hipertensão arterial, tabagismo e fator reumatoide, bem como o nível da proteína C-reativa (CRP). O DNA foi extraído e foram analisados os polimorfismos de nucleotídeo único (SNP) nas posições -607C/A e -137G/C do gene IL-18 em ambos os grupos. O equilíbrio de Hardy-Weinberg (EHW) e o odds ratio (OR) foram realizados, considerando IC 95% e P < 0,05. RESULTADOS: As frequências do alelo -607A nos pacientes com AR e nos controles foram de 0,443 e 0,424 e do alelo -137C foram de 0,304 e 0,291, respectivamente. As frequências do genótipo estavam em EHW, exceto em controles no locus -137 (P = 0,006). Não foi encontrada associação dos polimorfismos do gene IL-18 com AR, nem com fatores de risco de DCV, incluindo o nível do colesterol e de CRP (P > 0,05). Além disso, observaram-se mais indivíduos fumantes entre pacientes com AR em comparação aos controles (OR = 1,691; P = 0,088), e os níveis de CRP eram ligeiramente mais elevados em pacientes fumantes quando comparados aos de pacientes não fumantes (OR = 2,673; P = 0,061). CONCLUSÕES: Ao analisar uma amostra de pacientes com AR no sul do Brasil, não foi encontrada associação dos polimorfismos do gene IL-18 com AR, nem com os fatores de risco de DCV. OBJECTIVE: To assess the association of the polymorphisms of the interleukin-18 (IL-18) gene with rheumatoid arthritis (RA) and with risk factors for cardiovascular diseases (CVD). METHODS: This sample comprised 97 patients with RA and 151 healthy controls. In the patients, risk factors for CVD were analyzed, such as cholesterol levels, arterial hypertension, smoking habit, C-reactive protein (CRP) level, and rheumatoid factor. DNA was extracted and the single nucleotide polymorphisms (SNP) at the -607C/A and -137G/C positions of the IL-18 gene were assessed in both groups. The Hardy-Weinberg equilibrium (HWE) was calculated and the odds ratio (OR) test performed, considering a 95% CI and P < 0.05. RESULTS: The frequencies of the -607A allele in patients with RA and in controls were 0,443 and 0.424, respectively, and of the -137C allele, 0.304 and 0.291, respectively. The genotype frequencies were in HWE, except for controls in the -137 locus (P = 0.006). Association of the polymorphisms of the IL-18 gene was found with neither RA nor risk factors for CVD, including cholesterol level and CRP (P > 0.05). In addition, more smokers were found among patients with RA as compared with controls (OR = 1.691; P = 0.088), and the CRP levels were slightly higher in patients who smoked than in patients who did not (OR = 2.673; P = 0.061). CONCLUSIONS: In this sample of patients with RA in the South of Brazil, association of the polymorphisms of the IL-18 gene was observed with neither RA nor risk factors for CVD.

Systemic Sclerosis (SSc) is an autoimmune disease of multifactorial etiology, triggered by a combination of genetic and environmental factors. Its varied clinical expression results from the complex physiopathogenic interaction of three main elements: proliferative vasculopathy, immune dysregulation and abnormal deposition and remodeling of the extracellular matrix (ECM), of which the characteristic disease fibrosis is the result. Early physiopathogenic events appear to be endothelial injury and imbalance in vascular repair with the activation of endothelial cells, the immune system and platelets, with the release of multiple mediators such as TH2 proinflammatory cytokines and growth factors, triggering a sequence of simultaneous or cascading events that involve several intracellular signaling pathways. The most important result of these events is the hyperactivation of fibroblasts, the main effector cells of fibrosis, which will then produce large amounts of ECM constituents and secrete multiple growth factors and cytokines that perpetuate the process. In this article we review the main factors potentially involved in the etiology of SSc and reexamine the current knowledge about the most important mechanisms involved in the development of lesions that are characteristic of the disease. A better understanding of these physiopathogenic mechanisms will help identify potential therapeutic targets, which may result in advances in the management of this complex and debilitating disease.

OBJETIVO: De acordo com alguns estudos, a associação de leflunomida (LEF) a pacientes portadores de artrite reumatoide não responsivos a metotrexato (MTX) aumentou a eficácia do tratamento, elevando, porém, o risco de toxicidade hepática. Este estudo objetiva avaliar a incidência de toxicidade hepática no tratamento da artrite reumatoide ativa usando terapia combinada de LEF e MTX em comparação com monoterapia com MTX. MÉTODOS: Entre fevereiro e setembro de 2009, foram arrolados 97 pacientes consecutivos acompanhados pelo Hospital Universitário da Universidade Federal de Santa Catarina, Brasil. Pacientes com artrite reumatoide em uso de MTX somente ou em combinação com LEF tiveram seus prontuários sistematicamente revisados. As enzimas alanino/aspartato aminotransferases foram analisadas retrospectivamente desde o tratamento com MTX ou MTX mais LEF. Hepatotoxicidade foi definida como um aumento das enzimas hepáticas acima de duas vezes o limite superior da normalidade. RESULTADOS: 71 pacientes foram incluídos no estudo: 36,6% usavam 20-25 mg/semana de MTX e 63,4% usavam 20-25 mg/semana de MTX associado a 20 mg/ dia de LEF. Dos pacientes em terapia combinada, 11,1% tinham níveis anormais das enzimas hepáticas versus 11,5% daqueles em monoterapia (P = 1,0). Níveis anormais de aminotransferases têm sido observados em pacientes com artrite reumatoide tanto em monoterapia com MTX quanto com LEF. Em nosso estudo, não encontramos diferença entre as percentagens de elevação das aminotransferases em pacientes tratados somente com MTX ou com terapia combinada. CONCLUSÃO: A combinação de MTX e LEF em pacientes com artrite reumatoide é geralmente segura e bem tolerada. OBJECTIVE: Some studies have reported that adding leflunomide (LEF) to the treatment of rheumatoid arthritis (RA) in patients who do not respond to methotrexate (MTX) improved efficacy but increased the risk of liver toxicity. This study aimed at assessing the incidence of liver toxicity in patients with active RA using the LEF and MTX combination therapy in comparison with that of patients on MTX monotherapy. METHODS: Between February and September 2009, 97 consecutive patients followed up at the University Hospital of the Universidade Federal de Santa Catarina, Brazil, were enrolled. RA patients on MTX alone or using the LEF and MTX combination had their medical records systematically reviewed. The alanine/aspartate aminotransferase enzymes were retrospectively analyzed since the beginning of treatment with MTX or MTX plus LEF. Hepatotoxicity was defined as an increase of at least two-fold the upper limits of normal of the liver enzymes. RESULTS: 71 RA patients were included in the study: 36.6% were using 20-25 mg/week of MTX alone and 63.4% were using 20-25 mg/week of MTX plus 20 mg/day of LEF. Of the patients on the combination therapy, 11.1% had abnormal levels of liver enzymes versus 11.5% of the patients on monotherapy (P = 1.0). Abnormal aminotransferase levels have been seen with both MTX and LEF monotherapies in patients with RA. In our study, no difference was found between the percentages of aminotransferase elevations of patients being treated with MTX alone or in combination with LEF. CONCLUSION: The combination of MTX and LEF in RA patients is generally safe and well tolerated.

INTRODUÇÃO: O termo polifarmácia, ou seja, a utilização concomitante de múltiplos fármacos pelo mesmo indivíduo vem sendo amplamente associado a pacientes institucionalizados e idosos, no entanto pode ocorrer em grupos de pacientes portadores de doenças crônicas como artrite reumatoide (AR). OBJETIVO: Quantificar a polifarmácia em um grupo de pacientes com AR e realizar um levantamento sobre o risco de potenciais interações indesejáveis entre os medicamentos utilizados no manejo dessa doença e os fármacos utilizados em enfermidades não crônicas. MÉTODOS: Realizou-se um estudo de coorte com 103 pacientes portadores de AR, atendidos no Componente Especializado da Assistência Farmacêutica/MS, Florianópolis/SC. Os pacientes foram acompanhados mensalmente, por meio de fichas. As interações medicamentosas foram identificadas pelo Drugdex System - Thomson Micromedex® - Interactions. RESULTADOS: Observou-se a presença de polifarmácia em 95,1% dos pacientes e de 19 potenciais interações indesejáveis entre os medicamentos utilizados por 74 pacientes, em média 3,0 ± 1,2 interações/paciente. Todas as potenciais interações estavam relacionadas a metotrexato. Omeprazol foi o principal representante, correspondendo a 29,3% delas, seguido por diclofenaco sódico (17,6%) e dipirona sódica (13,2%). CONCLUSÃO: Considerando que este estudo confirma que a polifarmácia é uma prática comum na terapêutica dos pacientes portadores de AR, deve haver maior vigilância acerca de efeitos adversos ou de redução da efetividade de determinados fármacos devido às suas interações farmacológicas INTRODUCTION: The term polypharmacy, meaning the concomitant use of multiple medications by one individual, has been widely reported in institutionalized or elderly patients. It can, however, occur in patients with chronic diseases, such as rheumatoid arthritis (RA). OBJECTIVE: To quantify polypharmacy in a group of RA patients and to assess the risk of potential undesirable interactions between medications used for managing RA and those used for non-chronic diseases. METHODS: A cohort study was carried out with 103 RA patients registered at the Strategy of Access to Medications from the Brazilian Health Ministry, at the School of Pharmacy of the city of Florianópolis, state of Santa Catarina. Patients were monthly followed up by use of form completion. Drug interactions were identified by use of the Drugdex System - Thomson Micromedex® - Interactions database. RESULTS: Polypharmacy was found in 95.1% of the patients, and 19 potential undesirable interactions were observed between the drugs used by 74 patients (mean of 3.0 ± 1.2 interactions/patient). All potential interactions were related to methotrexate. Omeprazole was the major representative, accounting for 29.3% of the interactions, followed by diclofenac sodium (17.6%), and metamizole sodium (13.2%). CONCLUSION: Considering that this study confirms that polypharmacy is a common therapeutic practice in RA patients, it is worth emphasizing the need for greater surveillance regarding the adverse effects or effectiveness reduction of certain drugs due to drug interaction

Calcification and ossification of the ligamentum flavum or of the posterior longitudinal ligament are causes of compressive myelopathy, more frequent in the lower thoracic levels, and extremely rare in Western populations. Surgical decompression is the only therapy, but the disease is usually progressive, and its recurrence after surgery is common. Inflammatory mediators might play a role in the progression of compressive myelopathy, but, to our knowledge, the therapeutic approach involving anti-inflammatory agents has never been tried before. We report a case of compressive myelopathy due to calcification of the ligamentum flavum, in which hyperproteinorachia and response to steroid therapy have been observed. Those data have not been published before and might provide new ideas for the disease understanding.

The Sjögren's syndrome (SS) is an autoimmune disease characterized by a lymphocytic infiltration of salivary and lacrimal glands. Hematological manifestations of primary SS (pSS) usually consist of mild anemia, thrombocytopenia, moderate neutropenia, and lymphopenia. Agranulocytosis is rarely reported and usually responds to immunosuppression. We report the case of a pSS patient who presented with refractory agranulocytosis. Bone marrow biopsy disclosed a hypocellular bone marrow with normal maturation of the granulocytic series. The patient was successively treated with high-dose prednisone, granulocyte-macrophage colony stimulation factor, and cyclosporine, with no hematological response. Mycophenolate mofetil (MMF) was initiated and after two months there was a rise on the white blood cell count. After one year of follow-up, she had neither further neutropenia episodes, nor infectious complications. We conclude that, in pSS refractory agranulocytosis, MMF can be an effective and well-tolerated treatment option.

Musculoskeletal conditions have an enormous and growing impact worldwide. In spite of that, some clinicians are not confident in their own musculoskeletal examination skills. This study aimed to evaluate the prevalence of musculoskeletal symptoms in an emergency room, and the frequency of musculoskeletal physical examination description on those cases.This was a cross-sectional study. We performed a systematic analysis of medical files at the emergency room of the University Hospital of the Federal University of Santa Catarina, Brazil, from April 24th to 30th, 2009.We analyzed 392 files, where 41.5% of patients were male and mean age was 38.7 ± 17.2 years-old. Sixty nine out of 392 patients (17.6%) presented with a musculoskeletal complaint. The most common musculoskeletal complaint was low back pain (33/69). Only 49.2% of patients with a musculoskeletal chief complaint had a specific physical examination registered on the files. Patients with musculoskeletal complaints had lower registrations of abdominal examination (46% versus 62%, P = 0.01) and vital signs (46% versus 66%, P = 0.002), but a higher frequency of musculoskeletal examination registration (49% versus 0.6%, P = 0.00).Our study confirms other observations worldwide. Musculoskeletal complaints are frequent in a emergency room setting and in spite of that it is suggested that musculoskeletal symptoms are poorly evaluated, which is probably related to an insufficient musculoskeletal education. It is essential that medical schools place more emphasis on these conditions so that young physicians will be more prepared to deal with these common diseases.

Some studies have reported that adding leflunomide (LEF) to the treatment of rheumatoid arthritis (RA) in patients who do not respond to methotrexate (MTX) improved efficacy but increased the risk of liver toxicity. This study aimed at assessing the incidence of liver toxicity in patients with active RA using the LEF and MTX combination therapy in comparison with that of patients on MTX monotherapy.Between February and September 2009, 97 consecutive patients followed up at the University Hospital of the Universidade Federal de Santa Catarina, Brazil, were enrolled. RA patients on MTX alone or using the LEF and MTX combination had their medical records systematically reviewed. The alanine/aspartate aminotransferase enzymes were retrospectively analyzed since the beginning of treatment with MTX or MTX plus LEF. Hepatotoxicity was defined as an increase of at least two-fold the upper limits of normal of the liver enzymes.71 RA patients were included in the study: 36.6% were using 20-25 mg/week of MTX alone and 63.4% were using 20-25 mg/week of MTX plus 20 mg/day of LEF. Of the patients on the combination therapy, 11.1% had abnormal levels of liver enzymes versus 11.5% of the patients on monotherapy (P = 1.0). Abnormal aminotransferase levels have been seen with both MTX and LEF monotherapies in patients with RA. In our study, no difference was found between the percentages of aminotransferase elevations of patients being treated with MTX alone or in combination with LEF.The combination of MTX and LEF in RA patients is generally safe and well tolerated.

Tumoral necrosis factor alpha blockers are very efficient in the treatment of many inflammatory systemic diseases, including rheumatoid arthritis and psoriasis. However, a paradoxical arouse of psoriasiform lesions may occur in a few patients taking anti-TNFα. The etiology of this rare side effect is still a mystery, and its treatment may be difficult. The authors report the resolution of adalimumab-induced psoriasis in a woman with rheumatoid arthritis after the use of high vitamin D(3) doses for the treatment of vitamin D deficiency. This is the first report of resolution of anti-TNFα-induced psoriasiform lesions by high doses of vitamin D(3) in a patient with rheumatoid arthritis and vitamin D deficiency. This case raises interesting questions on the role of vitamin D deficiency in the pathogenesis of this side effect and on the possible usefulness of high-dose vitamin D(3) in its treatment.

The term polypharmacy, meaning the concomitant use of multiple medications by one individual, has been widely reported in institutionalized or elderly patients. It can, however, occur in patients with chronic diseases, such as rheumatoid arthritis (RA).To quantify polypharmacy in a group of RA patients and to assess the risk of potential undesirable interactions between medications used for managing RA and those used for non-chronic diseases.A cohort study was carried out with 103 RA patients registered at the Strategy of Access to Medications from the Brazilian Health Ministry, at the School of Pharmacy of the city of Florianópolis, state of Santa Catarina. Patients were monthly followed up by use of form completion. Drug interactions were identified by use of the Drugdex System - Thomson Micromedex® - Interactions database.Polypharmacy was found in 95.1% of the patients, and 19 potential undesirable interactions were observed between the drugs used by 74 patients (mean of 3.0 ± 1.2 interactions/patient). All potential interactions were related to methotrexate. Omeprazole was the major representative, accounting for 29.3% of the interactions, followed by diclofenac sodium (17.6%), and metamizole sodium (13.2%).Considering that this study confirms that polypharmacy is a common therapeutic practice in RA patients, it is worth emphasizing the need for greater surveillance regarding the adverse effects or effectiveness reduction of certain drugs due to drug interaction.

Paget’s disease of bone (PDB) exhibits a marked geographic variation. In Brazil, the prevalence of PDB is unknown and only a few clinical data are available. The aim is to determine clinical, laboratory, imaging and response to treatment data in a large PDB case series in the city of Florianopolis, Brazil. We have performed a retrospective study based on charts reviews of all patients with PDB followed at the University Hospital of the Federal University of Santa Catarina and at five different private rheumatology outpatient offices in Florianopolis, between 1995 and 2009. One hundred and thirty-four patients with PDB were identified. Mean age at diagnosis was 63.2 ± 10.5 years, 67.2% were women, and 91.1% were Caucasian. Positive family history was reported in only 8.2%. Polyostotic disease was found in 75.0% of the cases, bone pain in 77.9%, and bone deformities in 15.9%. Higher levels of AP were significantly associated with polyostotic disease and skull involvement. Pelvic bones were the most frequently affected (53.7%). Complications included deafness in 8.2%, bone fractures in 3.0%, hydrocephalus in 2.2%, and cauda equina syndrome in 0.7% of the cases. Treatment with zoledronic acid achieved the best response with only 2.9% failing to respond adequately. According to literature data, PDB in South America seems to be characterized by an overall low prevalence, but with localized clusters with higher prevalence. The authors have described a cluster of PDB in Florianopolis, in Southern Brazil. Further properly designed studies are necessary to clarify the PDB epidemiology in South America.

Hypertrophic osteoarthropathy (HOA) is characterized by periostitis of tubular bones, thickened skin, and digital clubbing. Its pathogenesis is unknown but an inflammatory factor and increased bone remodeling have been implicated. It is a very rare disease, usually diagnosed late with few therapeutic options. Bone and joint pains are secondary to periostitis and are usually difficult to control. Tumor necrosis factor-alpha is a cytokine that induces other inflammatory cytokine production, has an osteoclastogenic effect in different rheumatic diseases and probably also has an important role in periostitis and the systemic inflammatory manifestations in HOA. We describe the case of a patient with the primary form of HOA, who had refractory bone pain and arthritis that responded partially to infliximab treatment.

Lung involvement in Sjogren's syndrome (SS) can affect trachea, bronchus, small airways, pleura and may cause interstitial lung injury. It may also be associated with malignancies, particularly non-Hodgkin's lymphoma, which is a well-recognized complication of this disease. Here we describe the occurrence of localized amyloidosis presenting as pulmonary nodules in a patient with newly diagnosed SS. We highlight this rare occurrence as a diagnostic possibility that should be considered in the evaluation of pulmonary involvement in this disease.