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O objetivo foi avaliar caracteristicas morfometricas de sementes, germinacao e crescimento inicial de plântulas de seis especies pertencente a familia Lamiaceae, endemicas da regiao semiarida do nordeste brasileiro e ainda pouco estudadas. Foram obtidos peso, comprimento, largura e conteudo de agua das sementes de Martianthus leucocephalus , Hyptis suaveolens , H. macrostachys , H. platanifolia , Eplingiella fruticosa e E. cuniloides e comparado o efeito da temperatura na germinacao e no crescimento inicial de plântulas das tres especies de Hyptis . As Sementes mostraram grande variabilidade; alguns parâmetros podem ser utilizados para fins de identificacao de especies. Sementes de Martianthus leucocephalus apresentaram menores medias para comprimento e largura, enquanto que as maiores medidas forma observadas em H. suaveolens . As temperaturas entre 25 e 30 o C foram as que proporcionaram as maiores porcentagens de germinacao e obtencao de plântulas vigorosas. Dentre as especies estudadas, as sementes de H. suaveolens apresentaram os maiores limites de tolerância termica.

Diabet. Med. Abstract Aims The objective of this cost-of-illness analysis was to quantify the annual costs associated with hospital admission for people with diabetes and foot ulcers in Brazil. Methods A hypothetical cohort was simulated using a decision tree model. Prevalence and incidence rates and clinical outcomes were estimated from published studies and applied to the general Brazilian population over 30 years. Costs were quoted in Brazilian real (BRL) and converted to US dollars ($US) at the 2008 currency exchange rate ($US1 = BRL 1.64). In the sensitivity analysis, we reduced and increased rates to assess the robustness of the cost estimates. Results In this hypothetical cohort there are 6.48 million (95% confidence interval 4.47–7.12) Brazilians citizens with Type 2 diabetes. Each year, approximately 323 000 (89 500–484 500) of these people develop foot ulcers and almost 97 200 (17 900–169 600) require hospital admission as a result. Each year, almost 46 300 (8500–80 900) limb amputations and 12 400 (2300–21 700) deaths occur as a result of diabetic foot disease in Brazil. The annual cost associated with these hospital admissions is estimated to be almost $US264m ($US51m–461m). The estimated cost for patients with amputation is nearly $US128m ($US24.5m–222.3m). Conclusions Our model shows that the social and economic impact of diabetic foot disease in Brazil is high. Government decision makers should reflect on the current situation and provide organized foot care throughout the whole country.

The present study describes resource utilisation in patients with ankylosing spondylitis (AS) treated at a tertiary public health facility over a one-year period. It also investigates the direct and indirect costs for society associated with the treatment of AS.Ninety AS patients were selected consecutively, and data was analysed retrospectively for one year. Resource utilisation was evaluated through systematic interviews with all patients. Demographic, socioeconomic, and clinical variables were recorded, and questionnaires evaluating quality of life, function, and disease activity were also applied (ASQoL, SF-36, HAQ-S, BASFI, and BASDAI). Estimates of indirect costs were performed using the human-capital approach based on the society perspective.Most of the patients were men (79%), with a mean age and disease duration of 40 and 16 years, respectively. The mean HAQ-S, BASFI and BASDAI scores were 1, 5, and 4, respectively. The mean ASQoL score for the sample was 8, and the mean Short-Form-36 scores were between 48 (body pain and general health) and 81 (emotional role). The average monthly household income for the group was US$ 520. The patients had an average of 6 outpatient visits, 6 physical therapy visits and 30 laboratory exams per patient, per year. The average total cost for society was US$ 4,597 per patient per year, of which 45% were direct costs and 55% were indirect costs.Ankylosing spondylitis is a disease that represents a considerable burden to Brazil. It is extremely important to carry out studies that assess the costs of chronic diseases, especially in developing nations, in order to determine the best manner of allocating the already scanty resources in such regions.

The objective of this cost-of-illness analysis was to quantify the annual costs associated with hospital admission for people with diabetes and foot ulcers in Brazil.A hypothetical cohort was simulated using a decision tree model. Prevalence and incidence rates and clinical outcomes were estimated from published studies and applied to the general Brazilian population over 30 years. Costs were quoted in Brazilian real (BRL) and converted to US dollars ($US) at the 2008 currency exchange rate ($US1 = BRL 1.64). In the sensitivity analysis, we reduced and increased rates to assess the robustness of the cost estimates.In this hypothetical cohort there are 6.48 million (95% confidence interval 4.47-7.12) Brazilians citizens with Type 2 diabetes. Each year, approximately 323,000 (89,500-484,500) of these people develop foot ulcers and almost 97,200 (17,900-169,600) require hospital admission as a result. Each year, almost 46,300 (8500-80,900) limb amputations and 12,400 (2300-21,700) deaths occur as a result of diabetic foot disease in Brazil. The annual cost associated with these hospital admissions is estimated to be almost $US264m ($US51m-461m). The estimated cost for patients with amputation is nearly $US128m ($US24.5m-222.3m).Our model shows that the social and economic impact of diabetic foot disease in Brazil is high. Government decision makers should reflect on the current situation and provide organized foot care throughout the whole country.

The aim of this study was to evaluate in relation to diagnosis and treatment for Rheumatoid Arthritis (RA) patients Brazilian population, and compare the management offered to patients who are followed up in the public and private sectors.An electronic questionnaire was sent to 650 rheumatologists, members of the Brazilian Rheumatology Society (SBR) and who were attending adult RA patients in the public and/or private sector, who had a contact e-mail address available in the SBR register and agreed to take part in the survey.The rheumatologists estimated that 51.7% of the patients had had their disease diagnosed and of these, 56.1% were undergoing treatment. It was also estimated that 53.9% of the RA patients that was under treatment were being followed up by rheumatologists. The mean time interval estimated by the rheumatologists, between the appearance of the first symptoms of RA and the diagnosis made by a doctor, was greater among the patients who sought attendance in public services (1.8 years). There was no difference in clinical and radiographic assessment measures between the two types of service, with the exception of the application of HAQ, which was used more in public services. The principal drug association reported in both types of services was methotrexate and chloroquine. The rate of usage of associations between biological agents and methotrexate ranged from 6 to 8%. The main treatment-related difficulties were: access to the health system (public services) and cost of medication (private services).Approximately 50% of RA patients are being diagnosed and half of these are under treatment. There was no great difference in attendance within the public and private systems for these patients, whereas the main difficulty for the public system was access to attendance, for the private system it was the cost of the medication.

To describe and analyze resource utilization in patients with rheumatoid arthritis (RA) treated at a tertiary public health facility over a one-year period. Costs for the patient and for society associated with the treatment of RA were also investigated.One hundred consecutively selected RA patients were included. Resource utilization was evaluated retrospectively for one year. Systematic interviews were used in all patients and demographic, socioeconomic and clinical variables were recorded.One hundred patients were included. Most of the patients were women (92%) and had mean age and disease duration of 51 and 11 years, respectively. The majority of the patients were Steinbroker functional class I (48%). Mean HAQ score for the sample was 0.95 and mean Short-Form-36 scores were between 49.64 (bodily pain) and 70.00 (social functioning). The average monthly household income for the group was US$ 359. The patients had on average 4 outpatient visits and 21 laboratory exams per year. Drugs accounted for 59% of the total cost associated with RA. The average total cost for society was US$ 424.14 per patient per year, of which 95% were direct and 5% indirect costs.The management of RA patients is an important financial burden in Brazil. The effort to couple resource utilization with the best available evidence, associated with the limited funds available in the healthcare system (particularly in a developing country), emphasizes the importance of studies that critically evaluate resource utilization and cost in these chronic patients. The systematic use of such studies may prove helpful to optimize the health system.

Gastrooesophageal reflux disease (GERD) is highly prevalent in the Western world but its true population prevalence is difficult to estimate without a validated instrument to detect it. The evaluation of health-related quality of life (HRQoL) is an useful tool in this assessment. The aims of this study are to translate and validate a GERD specific HRQoL questionnaire and evaluate HRQoL in a Brazilian population before and after GERD treatment. GERD patients with typical symptoms and Los Angeles Classes A to C esophagitis were included in the study. Two HRQoL questionnaires and upper digestive endoscopy were performed before and after 6 weeks treatment with pantoprazole 40 mg/day followed by 80 mg/day for another 8 weeks if healing did not occur. A generic (SF-36) and one disease-specific questionnaire (GERD score) were used. The latter was translated and validated for Brazilian Portuguese. From January 2002 to December 2003, 100 patients were enrolled. Of these, 78 patients were evaluated in a per protocol analysis (35 men, mean age: 40 years). The translated questionnaire (Brazilian GERD Score, BGERDS) demonstrated adequate psychometric properties (validity, responsiveness and reliability). SF-36 and BGERDS domains significantly improved after treatment (P < 0.01 and P < 0.001 respectively). The BGERDS was shown to be valid and reliable. Patients with esophagitis showed an impaired HRQoL that improved or normalized after treatment with pantoprazole.

The resource utilization and cost of 51 episodes of febrile neutropenia in children with leukemia and lymphomas who were admitted to the Pediatric Oncology Institute (GRAAC) of the Federal University of São Paulo were analyzed. Patients aged 60 days to 21 years with confirmed diagnoses of acute myeloid leukemia, acute lymphoid leukemia, non-Hodgkin lymphoma, or Hodgkińs disease who presented axillary temperature above 38 degrees C at least once episode, or between 37.5 degrees C and 38 degrees C on three occasions during a 24-h period, neutrophil count below 500/mm(3), or between 500/mm(3)and 1,000/mm(3) but expected to fall below 500/mm(3) were included in the study. The patients' ages varied between 1 and 15.6 years, and 67% of the patients were male. The median cost per treated episode was US dollars 2,660 (2,039). Hospitalization costs accounted for 62% of the total cost of the treatment, antibacterials accounting for 23%. Episodes in patients with documented infections had a higher median direct cost than episodes in patients with fever of unknown origin (P=0.018). There was a trend for a higher median direct cost in episodes among patients with a worse prognostic factor, such as type of underlying disease, presence of documented infection, and longer duration of neutropenia. This is the first study to evaluate the economics of febrile neutropenia episodes in Brazil, and serves as a basis for resource utilization and costs incurred in the treatment of such patients in this country.

Osteoporosis is characterized by low bone mass, deterioration of the microarchitecture of the bone tissue and increase susceptibility to fractures. Clinical manifestations are fractures and their complications. The most common fractures are hip,spine and wrist, although any bone is susceptible.To assess the resource utilization and the annual costs incurred by patients with postmenopausal osteoporosisOne hundred consecutive patients were studied in the Universidade Federal de São Paulo. The inclusion criteria were: postmenopausal osteoporosis (WHO 1994) for at least one year b) at least one year attending the outpatient clinic, minimal comprehensive and speaking conditions. The socioeconomic and clinical characteristics, the resource utilization and costs in the last year were assessed using 2 questionnaires. The unitary costs were based in the Public Healthcare System Index (1998).The mean age was 66 years and the monthly family income was R$ 534.14 (US$ 456 - in 1998). There was a mean of 7 visits/patient/ year. 77% of the patients used calcium and 38% used estrogens. The mean total annual costs for osteoporosis treatment, considering societal perspective, were R$ 908.18 (US$ 776-in 1998) per patient per year.The costs related to osteoporosis treatment represented 11% of the mean monthly household income from the patients' perspective (R$ 534=US$ 456). As the population is ageing and the osteoporosis incidence is increasing, health policy should be implemented to rationally allocate the scarce resources available, based on economic analysis.

The socioeconomic effects of rheumatic fever (RF) in Brazil, including direct and indirect costs to patients and their families and to society, are largely unknown. We evaluated the utilization of resources and costs related to RF in a tertiary center caring for low income patients in the city of São Paulo, Brazil.One hundred patients with RF, younger than 18 yrs, with followup of at least one year, were sequentially selected to provide complete information on a questionnaire. Additional data were collected from patients' charts. The utilization of resources was evaluated for each patient throughout the entire disease course. Costs were determined for patients and their families as well as for the society, using variables from 3 different systems: the national public health system, used by most lower income groups; the Brazilian Medical Association, which regulates charges and fees utilized by health plans and insurance companies; and costs charged by private practitioners, paid directly by patients.The RF population studied belonged to a low socioeconomic level. The mean monthly family income was $625.20 US. The mean disease duration was 3.9 yrs (range 1-10). Patients had a total of 1657 medical consultations, 22 hospital admissions, and 4 admissions to intensive care unit. Work absenteeism among parents was calculated as 22.9%, equivalent to 901 days of missed work; about 5% of the parents lost their jobs. Patients showed a high rate of school failure (22%). Considering the public system as a reference, direct, indirect, and total costs to society per 100 patients throughout the entire disease duration were $105,860 US ($271/patient/yr), $18,803 US ($48/patient/yr), and $124,663 US (US $319/patient/yr), respectively. When health care plan and private systems were taken as reference, the total costs were $423,550 US and $684,351 US, respectively.RF and rheumatic heart disease have an important socioeconomic impact in Brazil; costs of RF made up roughly 1.3% of annual family income. The estimated annual cost of RF for society in Brazil is $51,144,347.00 US.

To evaluate the construct validity of the Medical Outcomes Study Questionnaire 36-Item Short Form Health Survey (SF-36) and to assess the quality of life of patients with end-stage renal disease (ESRD) at the initiation of maintenance dialysis treatment.Cross-sectional study.Eight ambulatory dialysis units in São Paulo city, Brazil.Eighty ESRD patients at the initiation of chronic dialysis program and consecutively accepted for treatment in selected units in 1998.Quality of life as measured by the dimensions of the SF-36 questionnaire. The 'Kidney Disease Questionnaire' was used in a subgroup of patients to evaluate the validity of the SF-36.Median (range) scores of the SF-36 dimensions (ranging from 0 to 100, higher scores representing better quality of life) were: Physical Function 70 (0-100), Role Limitations due to Physical Problems 25 (0-100), Bodily Pain 62 (0-100), General Health 57 (5-100), Vitality 55 (10-100), Social Function 63 (0-100), Role Limitations due to Emotional Problems 34 (0-100) and Mental Health 68 (0-100). SF-36 dimensions correlated significantly with those of the 'Kidney Disease Questionnaire' (correlation coefficients ranging from 0.23 to 0.68).The SF-36 was shown to have construct validity when used in patients with ESRD in Brazil. The quality of life of ESRD patients is impaired at the initiation of dialysis treatment and this was clearly evidenced in the Role Limitations due to Physical Function and Emotional Function items. Greater attention should be given to interventions that could improve the quality of life parameters at the initiation of dialysis treatment.

Rheumatoid arthritis (RA) is a chronic and disabling disease frequently leading to physical and psychological dependence, with considerable economic consequences. Responsibility for care of the patient is taken on by a member of the family called the primary caregiver. Studies of caregivers of patients with RA are scarce. A better understanding of the caregiver's situation could provide interventions that reduce the burden and postpone institutionalization of people with arthritis disability. Our objective was to assess the effect of RA on the quality of life of primary caregivers.Sixty-two patients from the rheumatic disease outpatient clinic and their respective caregivers were interviewed. Demographic and clinical data were recorded. Health and psychological status were measured using the Health Assessment Questionnaire (HAQ), Medical Outcomes Survey Short Form 36 (SF-36), Self-Reporting Questionnaire (SRQ-20), and a numerical pain rating scale. Burden of disease on the caregiver was assessed by the Caregiver Burden scale (CB scale).The majority of caregivers were women (82.3%), married (59.7%), mean (SD) age of 39.7 (15.7) years, with children/son (32.7%) or spouse (24.2%), with low education level and low income. Thirty-seven percent displayed psychoemotional disturbance measured by SRQ-20. Emotional aspect and mental health (by SF-36) were the most affected. The mean (SD) score of total burden experienced was 1.82 (0.59). The quality of relationship between caregivers and patients and SF-36 mental health of caregivers were important predictors of burden.Caregivers of patients with RA show high prevalence of psychological disturbance. The quality of the relationship between caregivers and patients and the mental health of the caregiver are important predictors of the burden of disease.

The purpose of this study was to translate into Brazilian-Portuguese the Osteoporosis Assessment Questionnaire (OPAQ), and to evaluate its reliability and validity.The OPAQ was translated into Brazilian-Portuguese. This version was then back-translated into an English version which was compared to the original version, and a second Brazilian-Portuguese version was generated. This draft version of the Brazilian-Portuguese OPAQ was administered to 30 patients with lumbar osteoporosis and no fractures. The non-applicable questions were modified and, after being administered again, this Brazilian-Portuguese version of the OPAQ was accepted as definitive. Its reliability was tested in 30 osteoporotic out-patients, and was administered three times to the patients to check the intra/interobserver reliability. The patients were also clinically evaluated using HAQ, FIQ and a numerical rating scale for pain. For all patients the number of fractures and the bone mineral density at the spine were determined.The mean age of the patients was 69 years (54 to 89 years) and the mean number of fractures was 2.72. Twenty-one patients (70%) had had more than one vertebral fracture. All of the questionnaire components, except for mood (c16), presented statistically significant coefficients for intra/interobserver reliability. The highest score was observed for "the fear of falling" (6.70). Correlations between the OPAQ components and the number of fractures, bone density and Z-score were not statistically significant.This Brazilian-Portuguese version of the OPAQ is a reliable and valid instrument. Other aspects than bone mineral density and the number of fractures have an important influence on the quality of life in patients with osteoporosis and fractures.

Different instruments are available to measure functional status in juvenile rheumatoid arthritis (JRA); however, none is based on the evaluation of joint range of motion (ROM). We designed and evaluated a ROM scale to be used as a complementary instrument in daily practice with JRA as well as in trials.The 10 joint movements of the Pediatric Escola Paulista de Medicina Range of Motion scale (Pediatric EPM-ROM) were derived from 25 initial movements. The selection was based on 2 criteria: (1) consensus among 3 pediatric rheumatologists, one physical therapist, and one occupational therapist; and (2) choice of movements that presented the highest scores in a pilot study involving patients with JRA. The score for each joint ranges from 0 (full movement) to 3 (severe limitation) and the cutoff degrees of motion are, in general, based on the lack of ability to perform some activities of daily living. The test-retest reliability was assessed by administering the scale twice by the same observer, 4 to 10 days apart, always in the morning. The interobserver reliability was evaluated on the same day by 2 independent observers. Cross sectional construct validity was also assessed by correlating the values of some clinical variables with the scores of the Pediatric EPM-ROM scale.The instrument was applied to 34 patients with JRA, 11 systemic, 11 polyarticular, and 12 pauciarticular. The mean EPM-ROM score was 0.57 (SD 0.54, min 0, max 2.05). The test-retest and interobserver correlation coefficients were 0.96 and 0.98, respectively. The Pearson correlation coefficients comparing scores of the Pediatric EPM-ROM scale and other variables were satisfactory: Childhood Health Assessment Questionnaire, r=0.55 (p0.001); American College of Rheumatology global functional class, r=0.56 (p0.001); and number of limited joints, r=0.65 (p0.001).Our results provide evidence that the Pediatric EPM-ROM scale is a valid instrument to measure joint ROM in JRA.

(1) To adapt the Community Oriented Programme for the Control of Rheumatic Disease (COPCORD) Core Questionnaire (CCQ) for use as a rheumatic disease screening instrument in Spanish and Portuguese communities in Brazil, Chile, and Mexico, including translation and back translation, and assessment of cross cultural equivalence and reliability. (2) To determine the screening characteristics of the CCQ, specifically the sensitivity and specificity of Spanish and Portuguese versions for detecting cases of rheumatic disorder compared with a full clinical examination by a rheumatologist. (3) To determine the number of clinical examinations that could be avoided in population studies by applying the CCQ followed by a clinical examination in positive CCQ screenees.Translation and assessment of cross cultural equivalence were conducted by practising rheumatologists in Brazil, Chile, and Mexico using standardized methods. Back translation was done by an independent rheumatologist (Brazil), a radiologist (Chile), and a general physician (Mexico). Interviewer agreement was assessed in all sites in a convenience sample. Sensitivity and specificity were assessed by independently administering the CCQ and a full clinical examination to a sample of 200 persons aged 15 years or older, randomly selected from communities in Sao Paulo, Brazil (n = 200), Temuco, Chile (n = 200), and Mexico City, Mexico (n = 200).(1) Cross cultural equivalence and back translation of the modified questionnaire were satisfactory. Interviewer agreement was acceptable. (2) In groups from Brazil, Chile, and Mexico, respectively, the overall prevalence of rheumatic disease based on clinical examination was 33.3, 45.1, and 46.3%. The sensitivity and specificity of 2 definitions of a positive CCQ screening for the presence of rheumatic disorder were: Definition 1 (no trauma, present pain, tenderness, swelling or stiffness in bones, joints or muscles): sensitivity, 91.8, 96.0, 84.0; specificity, 70.0, 35.5, 61.0; Definition 2 (Definition 1 plus pain intensityor = 4 and 11 point category rating scale): sensitivity, 66.2, 86.3, 42.7; specificity, 82.3, 41.9, 80.0. (3) In groups from Brazil, Chile, and Mexico, respectively, positive screening by Definition 1 followed by a clinical examination avoids 499, 213, and 403 clinical examination per 1000 respondents screened and yields an overall prevalence of rheumatic disorder of 30, 43, and 40%. The addition of pain intensity (Definition 2) increased the total number of examinations avoided, but reduced the prevalence estimate compared to Definition 1 (22.0, 39.0, and 20.0%).The CCQ appears promising as a screening tool to detect rheumatic disorder in Spanish and Portuguese speaking communities in a developing country. The findings suggest that the CCQ followed by a full clinical examination in positive respondents can provide an acceptable estimate of prevalence of rheumatic disorder. The total number of clinical examinations that must be administered in population based prevalence surveys can be reduced by using the CCQ, while maintaining satisfactory accuracy. Our findings need to be confirmed in further applications of the CCQ.

To evaluate the sensitivity and specificity of the ESSG criteria when applied to Brazilian patients with SpA and control patients with other rheumatic diseases.Seventy patients with spondylarthropathies and 62 patients with other rheumatic diseases were interviewed, examined and had their charts reviewed. The diagnoses of the diseases were based on published diagnostic guidelines or classification criteria. Data were also collected according to the ESSG criteria.The sensitivity and specificity of the ESSG classification criteria were 98.5% and 88.7%, respectively. The sensitivities of the criteria in the different subgroups of SpA ranged from a low of 97.7% in AS to a high of 100% in other SpA studied.Despite differences in the socio-cultural and geographic characteristics and in individual disease frequencies, the ESSG preliminary classification criteria performed well when applied to Brazilian patients.

Twenty-eight patients with Behcet's Disease (BD), diagnosed according to at least one of the published and internationally recognized diagnostic criteria (Japanese Committee, International Committee, O'Duffy, Mason & Barnes and James) were compared with 56 controls with other rheumatic diseases paired by sex and age.

A number of factors may affect the cost effectiveness of treatments and can cause this to vary by location. These factors include the patient population, relative price levels, clinical practice patterns and incentives to health professionals and institutions such as hospitals. This paper illustrates these issues by assessing the relative cost effectiveness of 3 nonsteroidal antiinflammatory drugs (NSAID), with different levels of gastrointestinal side effects, in 3 countries. We conclude that the relative cost effectiveness of drugs is not only dependent on drug price but may also vary by country.

To evaluate the potential role of environmental agents in the etiopathogenesis of Behçet's disease.Twenty-eight Behçet's disease patients and 56 controls were recruited prospectively from the outpatient rheumatic disease clinic at the Escola Paulista de Medicina between July 1991 and July 1992. Behçet's disease was diagnosed using one of the accepted sets of criteria (Japanese Committee, International Committee, O'Duffy, MasonBarnes, and James). The control patients, who had other rheumatic diseases, were matched on age and sex with the Behçet's disease patients. To investigate environmental factors, a standardized questionnaire was administered to each subject during an interview. Clinical and laboratory investigations were performed in each subject according to a predefined protocol.Analysis using the Chi-square test or Fisher's exact test (Cochran's restriction) disclosed significant associations between Behçet's disease and a history of herpes simplex virus type 1 infection or streptococcal infection.Despite the small sample size, our data strongly support a role of infectious agents in the etiopathogenesis of Behçet's disease. Further studies in larger patient populations are needed to confirm our results.

To determine in a Canadian health care setting the cost effectiveness of urate lowering drugs (ULD) in the treatment of nontophaceous gouty arthritis with recurrent attacks and to evaluate the least costly regimen among available ULD.A decision analysis model was designed using hypothetical cohort of patients who present 1 to 4 recurrent attacks/year. It incorporated costs and probabilities estimated from the published literature. Effectiveness was defined as the number of recurrent attacks averted by each treatment strategy (ULD or No ULD). The incremental cost effectiveness ratio was defined as the ratio of the additional cost incurred by a management strategy compared with the additional benefit derived from it. A multiway sensitivity analysis was built to allow the modelling of extreme case scenarios favoring (best ULD scenario) and disfavoring (worst ULD scenario) the ULD therapy.Using the baseline scenario estimates for the hypothetical cohort of patients presenting one attack/year, the total annualized costs per patient associated with ULD and No ULD treatment were Cdn $426.27 and 267.27, respectively. The average cost effectiveness ratios were $592.25 and 5,345.37, respectively, per attack averted. For this cohort of patients the incremental cost effectiveness ratio ranged from $99.59 (best ULD scenario) to 489.26 (worst ULD scenario). The treatment with ULD is cost saving if patients present 2 or more attacks/year. Allopurinol in its generic formulation was the ULD that presented the lowest incremental cost effectiveness ratio.ULD treatment is cost effective. It is also saving if patients present 2 or more recurrent attacks/year.

To evaluate and compare the quality of life of patients with fibromyalgia (FM) and rheumatoid arthritis (RA).Forty-four women with FM and 41 with RA were studied. There were 3 evaluations, with a 3-month interval. Besides special and general clinical examinations, the following tests were applied: pain numerical scale (PNS), Health Assessment Questionnaire (HAQ), Fibromyalgia Impact Questionnaire (FIQ), Arthritis Helplessness Index (AHI), Modified Post-Sleep Inventory (PSI), and questions about sleep disorders and socioeconomic impact.Results include the following: tender points (TP): FM = 13.9, RA = 2.9; PNS: FM = 7.2, RA = 6.8; HAQ: FM = 0.90, RA = 1.22; FIQ: FM = 47.2, RA = 42.5; AHI: FM = 32.7, RA = 31.8; sleep quality--mean duration of daily sleep: FM = 6.7 h, RA = 6.1; PSI scores: FM = 64.6, RA = 57.2. On questioning regarding economic impact, there was a decrease in family income for 65% of patients with FM and 75.1% for those with RA. Fifty-five percent of patients with FM and 66.6% of those with RA received social security aid. At followup evaluation, there was a statistically significant improvement in the following items for the patients with FM: TP count, HAQ, and AHI. The patients with RA improved in number of TP and AHI.FM has a negative impact on quality of life, similar to RA. Clinical, functional, and economic problems related to the disease were observed. The alteration observed remained relatively stable during the study period, except for physical disability.

Over the past two decades in Latin America, there has been a slow but definite upsurge in studies on the epidemiology of RD but, thus far, the data on the distribution and determinants of RD in the population are limited, and knowledge of time trends and geographical differences in disease risk are lacking. It is still not clear what proportion of disabilities are due to RD. The impact of RD on communities in developing countries is believed to be substantial, due to the cost of treatment and rehabilitation, and loss of earnings. There are important gaps in our knowledge, leaving unanswered such questions as the cost of treatment and rehabilitation, and loss of earnings. There are important gaps in our knowledge, leaving unanswered such questions as the cost to society of RD and the potential impact of RD prevention on the overall burden of disability. It is also important to point out, however, that from the relatively simple descriptive studies which dominated the RD literature a few years ago, we are now witnessing a shift towards increasing sophistication in study design and incorporation of multicentre collaboration. The rheumatologists and epidemiologists in LA who have managed to continue their work merit admiration. Even with unavoidable omissions, this summary demonstrates that the epidemiology of RD is alive and well in LA, where it has managed to continue to function under extremely difficult conditions. Yet, few methodologists appear to have directed their attention to the unique challenges of conducting studies in a resource-poor environment.(ABSTRACT TRUNCATED AT 250 WORDS)

The purpose of this study was to use the utility approach to evaluate the risks and benefits of corticosteroid therapy in rheumatoid arthritis patients. The utility approach provides us with a quantitative measure of the value or preference a patient attaches to his overall health status defined on a scale from perfect health (1) to death (0). Benefits and toxicity are combined into a number reflecting the patients combined assessment of the benefits of treatment and the side-effects associated with it. Utility of 3 scenarios (rheumatoid arthritis patients treated respectively with no, 5 mg/day and 15 mg/day of prednisone) were determined through the time trade-off (TTO) and thermometer scale (TS) techniques. Twenty-five rheumatoid arthritis patients selected at random among subjects attending an outpatient clinic and 25 rheumatologists were interviewed using visual aids. Treatment with 15 mg/d prednisone was assigned the highest utilities by both patients and physicians. Coefficients of correlation between thermometer scale and time trade-off utilities were 0.675 (p0.01) for physician-assigned utilities and 0.518 (p0.05) for patient-assigned utilities. Medical decisions concerning rheumatoid arthritis patients should take into account the preferences of patients and physicians.

Although commonly used, the 1982 revised criteria for the classification of Systemic Lupus Erythematosus (SLE) have not been completely evaluated in pediatric patients. This study was aimed at evaluating the sensitivity and specificity of the 1982 revised criteria when applied to pediatric patients.One hundred and three children with SLE and 101 children with other rheumatic diseases were selected from 5 rheumatology centers in Brazil. Diagnosis of SLE by the 1982 criteria were compared with our clinical diagnosis. The diagnosis of other diseases was made according to internationally accepted classification criteria or, when these were not available, according to the physician's own experienced judgement.The median number of criteria fulfilled by the patients with SLE and the controls were 6 and 1, respectively. The most common criteria observed in children with SLE were: abnormal antinuclear antibody titers (94%), arthritis (83%), immunologic disorder (83%), hematologic disorder (70%), malar rash (67%), and photosensitivity (58%). When the immunologic disorder was broken down into its constituent elements, antibodies to dsDNA and Sm were observed in 73.0% (65/89) and 31.4% (15/48), respectively. The sensitivity and specificity observed were 96% and 100%, respectively.The 1982 classification criteria can be successfully applied to children with SLE. These criteria may serve as a basis for multi-center collaborative studies on children with SLE.

The frequency of "pararama" occupational accidents between 1988 and 1990 as well as some associated clinical manifestations are herein reported. Data were collected at an industrial rubber tree plantation, in the northern part of Brazil and compared with data similarly collected from 1971 to 1974 on the same plantation, before starting protective measures. "Pararama" is the popular name of the larval form of a native insect of the Amazonian region, Premolis semirufa. During the study period, the annual average number of latex extractors was 337 and 60 accidents caused by "pararama" were registered. The annual average number of accidents per worker from 1971 to 1974 was 0.117 and in the period of this study, 0.063 (p = 0.061). Nineteen injured subjects were clinically evaluated and 13 of them were symptomatic. There was a statistically significant association between multiple accidents and the presence of symptoms (p = 0.001). "Pararamose", an occupational arthropathy, which may evolve with functional impairment of the affected joint, can be prevented with the latex extractors education and the institution of prophylactic measures, such as the use of gloves, boots and protective glasses.

In order to evaluate the pattern of ANA testing solicitation, 506 patients with ANA testing requested from July 1st. 1988 to December 31st, 1988, had their charts reviewed. These patients, randomly selected, were regularly attending the outpatient clinic at the "Escola Paulista de Medicina" (EPM). 289 patients were followed up at the Rheumatology Division (group A) and 217 patients at other clinical divisions at EPM (group B). The diseases that most frequently motivated the request for ANA test were: group A--SLE (22.5%), RA (18.0%), undefined arthropathies (6.2%), PSS and CREST (5.9%) and Raynaud phenomena (5.5%); and group B--rheumatic diseases (24.4%), nephropathies (17.1%), neuropathies (16.6%), dermopathies (7.8%), hemopathies (4.6%), pneumopathies (4.2%) and ophthalmopathies (3.7%). The positivity of ANA test in groups A and B was 32.9% and 17.5% respectively. 94 SLE patients were clinically diagnosed. The positivity of ANA and anti-dsDNA tests in this group was respectively 85.1% and 26.6%. The sensitivity and specificity of 1982 ARA revised criteria were 94.7% and 99% respectively. The likelihood ratio (LR) of a positive or a negative test was established for this population. LR of a positive test was 6.5 while for a negative test it was 0.17. The ANA test, although lacking specificity, has been commonly requested by different specialties in order to practically rule-out the diagnosis of some connective rheumatic diseases. Immunofluorescence technique (IF) using antibodies conjugated with fluorochromes. was first described by Coons et al. in 1941. This method has been used as an important diagnostic tool in routine laboratory tests ever since.(ABSTRACT TRUNCATED AT 250 WORDS)

The diagnosis of rheumatic fever (RF) continues to be a difficult one in Pediatrics, mainly because of the polymorphism of its clinical presentation and the lack of specific laboratory test. Among the Jones' major criteria, arthritis is the most frequent and the least specific. Ninety three children with RF who presented 117 flares of the disease were studied in the Department of Pediatrics, Escola Paulista de Medicina, between Dec. 1989 and Dec. 1991. The presence of arthritis was defined as an inclusion criterion. The diagnosis was based on history, physical and laboratory examinations (Modified Jones' Criteria). The mean age was 10 years and the sex ratio was 1 male: 1.4 female. In 45% of the flares, arthritis was the only major criterion. In 44% there were arthritis and carditis, in 7% arthritis and chorea and in 4% arthritis, carditis and chorea. In 64% of the flares the pattern of articular involvement was migratory and in 36% addictive. Polyarthritis and oligoarthritis were observed respectively in 64% and 36%. Monoarthritis was reported in 3%. The definitive diagnosis of RF with atypical articular involvement only was possible in the presence of carditis or chorea. The authors conclude that physicians should be aware of the atypical involvement observed in some cases of RF, specially when arthritis is the only major criterion.

Sydenham's chorea (chorea minor, St. Vitus dance, rheumatic encephalitis), described by Thomas Sydenham in 1686, is considered one of the major manifestations of rheumatic fever (1, 2, 3, 4). Clinically it is characterized by involuntary movements, hypotonia, dysarthria, emotional disorders, and less frequently, by other neurological manifestations such as weakness, headache, seizures and sensory abnormalities (1,4). The motor disorders may be generalized or unilateral, in this case constituting a hemichorea (3). Chorea may present associated to other rheumatic fever manifestations during an acute episode, or in isolated form, characterizing the so-called "pure" chorea (5, 6, 7). Its etiology and pathophysiological mechanisms are still unclear, although its relation with a previous pathophysiological group A Beta-hemolytic streptococcus infection is well established (8). There is also evidence of the participation of immunological mechanisms in its pathogenesis, such as the finding of serum anti-nucleus caudatus and anti-subthalamic antibodies (9) and increase in IgG levels in cerebrospinal fluid of patients with chorea (10). In developed countries due to the reduction in rheumatic fever incidence and decrease in frequency of chorea as its manifestation (3, 11), the latter has become rare. However, in developing countries rheumatic fever remains a public health problem. In Brazil, in the last years an increase in the incidence of chorea has been observed as part of the clinical picture of rheumatic fever (12). The present study reports the clinical and laboratory findings of 187 cases of Sydenham's chorea followed-up during the period of January 1980 to December 1990 in two university centers in the city of Sao Paulo, Brazil.

At present there is no widely accepted therapy for ankylosing spondylitis (AS), a progressive debilitating disease. The effectiveness of sulfasalazine in AS still lacks strong evidence, as well, the magnitude of its benefit is unknown. A meta-analysis was carried out to assess the effectiveness of sulfasalazine in AS. A search of the literature was done using Medline, Index Medicus, the reference lists of articles located and contacting content experts to reveal unpublished studies. Five randomized controlled trials (RCT) comparing sulfasalazine to placebo were located and assessed methodologically. The methodologic quality of all 5 RCT was considered satisfactory and consequently these studies were included in the meta-analysis. The pooled estimate of clinical benefit (and its 95% confidence interval) favoring sulfasalazine, over and above that observed in the placebo group was as follows: Duration of morning stiffness -28.2% (-54.6 to -1.8%); severity of morning stiffness -30.6% (-52.5 to -8.7%); severity of pain -26.7% (-44.3 to -9.1%); general well being -7.1% (-24.3 to 10.0%); erythrocyte sedimentation rate -9.2% (-24.8 to 6.4%); and IgA -11.7% (-18.8 to -4.7%). Adverse effects, mostly mild, were more frequently observed in the sulfasalazine group (odds ratio [OR] = 1.5746, p = 0.1082). The occurrence of dropouts (OR = 1.1554, p = 0.6119) was similar in both groups. Sulfasalazine is a safe and effective drug in the short term treatment of AS.

Different tools are available for the measurement of functional status; however, only a few of them are based on the evaluation of the joint range of motion (ROM). This study is aimed at the design and evaluation of the measurement properties of a ROM scale to be used as an evaluative instrument in rheumatoid arthritis (RA) trials. The EPM-ROM Scale evaluates 10 distinct movements of the small and large joints. The score of each joint varies from 0 (full movement) to 3 (severe limitation) and the cut-off degrees of motion are, in general, based on the lack of ability to perform some determined activities of daily living. The test-retest characteristic of the scale was assessed by administering the scale twice, 5 days apart, to 35 RA patients. The product moment correlation was 0.775 (P less than 0.001). The cross-sectional construct validity of the scale was assessed by the concomitant scoring of the EPM-ROM Scale and the functional ability dimension of the Health Assessment Questionnaire (a reliable, valid and responsive instrument) in these patients. The product moment correlation was 0.518 (P less than 0.001). The evaluation of its longitudinal construct validity and responsiveness are now in progress.

The assessment of a measure of chronic pain, should be reliable, valid and sensitive to change. Our study evaluated the reliability of 3 pain scales, visual analogue scale (VAS), numerical rating scale (NRS) and verbal rating scale (VRS) in literate and illiterate patients with rheumatoid arthritis (RA). Patients with RA attending an outpatient rheumatology clinic were interviewed and asked to score their pain levels on the 3 pain scales. The scales were presented in random order, twice, before and just after a regular medical consultation. Ninety-one patients were studied (25 illiterate and 66 literate). The Pearson product moment correlation between first and second assessment was 0.937 for VAS, 0.963 for NRS and 0.901 for VRS in the literate patient group and 0.712 for VAS, 0.947 for NRS and 0.820 for VRS in the illiterate patient group. These results indicate that the NRS has the higher reliability in both groups of patients.

The authors discuss the usefulness of the HLA-B27 test in the diagnosis of ankylosing spondylitis (AS). Sensitivity, Specificity, Predictive Value of a Negative Test, Predictive Value of a Positive Test, and Likelihood Ratio are defined and illustrated through the example involving HLA-B27 and AS. The HLA-B27 cannot be used as a screening test for the diagnosis of AS when evaluating an asymptomatic population, however the test is most useful in assisting the diagnosis of AS when used by physicians who understand the principles of probability.