Lung involvement prevalence in patients with early rheumatoid arthritis without known pulmonary disease: a multicentric cross sectional study

Abstract Background: Clinically evident interstitial lung disease (ILD) affects between 10 and 42% of the patients with rheumatoid arthritis (RA). Airway involvement seems to be even more common. Most of the available evidence comes from studies performed in established RA patients. The aim of our study was to know the prevalence of non-diagnosed lung disease (airway and interstitial involvement) in patients with early RA and look for associated factors. Methods: We designed an observational, multicenter, cross-sectional study, and included patients with RA of less than two years since diagnosis. We performed a structured questionnaire, HRCT and lung functional tests looking for lung disease, together with joint disease evaluation. We analyzed which variables were associated with the presence of lung disease on HRCT. Results: We included 83 patients, 83% females. The median (IQR) of time since RA diagnosis was 3 (1-6) months. In the HRCT, 57 patients had airway compromisea (72%), and 6 had interstitial abnormalities (7.5%). The most common altertion found in lung functional tests was a reduced DLCO (14%). The presence of at least one abnormality in the physical exam was associated with lung involvement on HRCT [13 (21.6%) vs 0 (0%); p = 0.026]. Also, patients with lung involvement presented significantly lower values of FVC% and DLCO%, and higher values of RV/TLC. No variable related to joint involvement was found associated with alterations in HRCT. Conclusion: Our study shows that a large proportion of early RA patients has abnormal findings in HRCT. Further studies are required to confirm these findings.

Artritis reumatoide, diagnóstico, evolución y tratamiento / Rheumatoid arthritis, diagnosis, evolution and treatment

La artritis reumatoide es la enfermedad inflamatoria más común en adultos con una alta prevalencia en la población general, invocando para su diagnóstico la presencia de al menos cuatro criterios de los orientados por el Colegio Americano de Reumatología, teniendo un papel protagónico en los últimos años la presencia de anticuerpos anti proteína citrulinada, así como los estudios de imágenes, que ayudan al diagnóstico de la artritis reumatoide temprana en el curso de los dos primeros años de evolución y sus orientaciones terapéuticas adecuadas, aspecto fundamental en la actualidad para evitar las lesiones erosivas irreversibles, que resultan en un marcado compromiso de la calidad de vida de los pacientes que la sufren, elementos que revisamos en este artículo de opinión(AU)

Rheumatoid arthritis is the most common inflammatory disease in adults with a high prevalence in the general population, invoking for its diagnosis the presence of at least four criteria of those guided by the American College of Rheumatology, having a leading role in recent years the presence of anti-citrullinated protein antibodies, as well as imaging studies, which help the diagnosis of early rheumatoid arthritis in the course of the first two years of evolution and its appropriate therapeutic orientations, a fundamental aspect nowadays to avoid irreversible erosive lesions , which result in a marked commitment to the quality of life of patients who suffer from it, elements that we review in this opinion article(AU)

Terapia biológica en la artritis reumatoide temprana: eficacia en la remisión de la enfermedad / Biological therapy in early rheumatoid arthritis: Efficacy in disease remission

Resumen Objetivo: Evaluar la eficacia de las terapias biológicas en inducir la remisión de la artritis reumatoide temprana. Métodos: Tipo de estudio: revisión sistemática de la literatura. Se realizó una búsqueda sistemática de la literatura en bases de datos electrónicas especializadas en ciencias de la salud: PubMed, Embase, Cochrane, LILACS, literatura gris (tesis doctorales, intervenciones en congresos, informes de entidades, trabajos no publicados) y búsqueda manual (búsquedas secundarias de los estudios citados en los artículos seleccionados). Criterios de inclusión: pacientes mayores de 18 arios con artritis reumatoide temprana (curso clínico menor de 12 meses) según criterios del Colegio Americano de Reumatología/Liga Europea contra el Reumatismo (ACR 1987, ACR/EULAR 2010), que recibieron terapia biológica en monoterapia o combinada con otros fármacos antirreumáticos modificadores de la enfermedad (FARME) y fueron incluidos en estudios clínicos controlados aleatorizados. Resultados: La revisión sistemática de la literatura identificó 978 estudios potencialmente relevantes; 86 fueron escogidos para la evaluación completa. Se excluyeron 68 artículos por no cumplir los criterios de inclusión, principalmente relacionados con el tiempo de duración de la enfermedad al diagnóstico de la artritis reumatoide temprana y con la metodología del estudio. Se realizó la síntesis cualitativa y cuantitativa de 18 estudios. Se identificó alto riesgo de sesgos en los estudios evaluados, y la síntesis de la evidencia, a través del metaanálisis, no evidenció diferencias con relación al desenlace remisión de la enfermedad al utilizar terapia biológica en monoterapia o combinada con FARME convencionales versus el uso de FARME (RR: 1,08; IC 95%: 0,94-1,23). Conclusiones: No hay diferencias en el desenlace de remisión de la enfermedad en pacientes con artritis reumatoide temprana que reciben terapia biológica versus pacientes tratados con FARME convencionales.

Abstract Rheumatoid arthritis is a chronic, systemic inflammatory disease, with a world prevalence of around 1%. The course of the disease may be changed by using synthetic and/or biological disease-modifying antirheumatic drugs alone or in combination. This review assessed whether the use of biological agents in early rheumatoid arthritis can lead to disease remission. Objective: To evaluate the efficacy of biological therapies in inducing remission in patients with early rheumatoid arthritis. Methods: Type of study: systematic review of the literature. A systematic search of the literature was made in specialized electronic health databases: PubMed, Embase, Cochrane, LILACS, gray literature (doctoral theses, congresses, entity reports, unpublished works) and manual search (Secondary searches of the studies cited in the selected articles). Inclusion criteria: Patients older than 18 years with early rheumatoid arthritis (clinical course less than 12 months) according to criteria of the American College of Rheumatology / European League against Rheumatism (ACR 1987, ACR/ EULAR 2010), who received biological therapy Monotherapy or combined with other disease modifying antirheumatic drugs (DMARDs) and were included in randomized controlled trials. Results: The systematic review of the literature identified 978 potentially relevant studies. Of the 86 that were chosen for a thorough evaluation, 68 articles were excluded. A qualitative and quantitative analysis of the remaining 18 studies was performed. A high risk of bias was identified in the studies evaluated and synthesis of the evidence did not show differences in the outcome of remission using biological therapy alone or combined with conventional DMARDs versus synthetic DMARDs (RR 1.08, 95% CI: 0.94-1.23). Conclusions: There is no difference in the outcome of remission in patients with early rheumatoid arthritis receiving biological therapy versus patients treated with conventional disease modifying antirheumatic drugs.

A new musculoskeletal ultrasound scoring system (US10) of the hands and wrist joints for evaluation of early rheumatoid arthritis patients / Novo sistema de escore ultrassonográfico (US10) musculoesquelético das articulações das mãos e punho para avaliação de pacientes com artrite reumatoide em fase inicial

ABSTRACT Objective: To propose a novel ultrasound scoring system for hand and wrist joints (US10) for evaluation of patients with early rheumatoid arthritis (RA) and to correlate the US10 with clinical, laboratory and functional variables. Methods: Forty-eight early RA patients underwent clinical and laboratory evaluations as well as blinded ultrasound (US) examinations at baseline, three, six and 12 months. The proposed US10 system involved the assessment of the wrist, second and third metacarpophalangeal and proximal interphalangeal joints. The score consisted of inflammation parameters (synovial proliferation [SP], power Doppler [PD] and tenosynovitis [TN]) and joint damage parameters (bone erosion [BE] and cartilage damage [CD]). SP, PD, BE and CD were scored qualitatively (0–1) and semi-quantitatively (grades 0–3). Tenosynovitis was scored as presence/absence. The evaluation also involved the 28-Joint Disease Activity Score (DAS28), Health Assessment Questionnaire (HAQ) and C-reactive protein level (CRP). Results: Mean duration of symptoms was 7.58 ± 3.59 months. Significant correlations (p < 0.05) were found between inflammation parameters and CRP at baseline and between the changes in these variables throughout the study. Significant correlations (p < 0.05) were found between DAS28 score and both PD and TN at baseline and between the changes in DAS28 score and both SP and TN throughout the follow up. Moreover, significant correlations were found between the changes in inflammation parameter scores and HAQ score throughout the follow up. Conclusion: The proposed US10 scoring system proved to be a useful tool for monitoring inflammation and joint damage in early RA patients, demonstrating significant correlations with longitudinal changes in disease activity and functional status.

RESUMO Objetivo: Propor um novo sistema de escore ultrassonográfico das articulações da mão e punho (US10) para a avaliação de pacientes com artrite reumatoide (AR) e correlacionar o US10 com variáveis clínicas, laboratoriais e funcionais. Métodos: Foram submetidos 48 pacientes com AR em fase inicial a avaliações clínicas e laboratoriais, bem como a exames cegos de ultrassom (US) no início do estudo e com 3, 6 e 12 meses. O sistema US10 proposto envolveu a avaliação do punho e das articulações metacarpofalângicas e interfalângicas proximais do segundo e terceiro dígitos. O escore consistiu em parâmetros inflamatórios (proliferação sinovial [PS], Power Doppler [PD] e tenossinovite [TN]) e parâmetros de danos articulares (erosão óssea [EO] e danos na cartilagem [DC]). PS, PD, EO e DC foram pontuados qualitativamente (0 a 1) e semiquantitativamente (graus 0 a 3). A tenossinovite foi pontuada como presença/ausência. A avaliação envolveu também o escore 28-Joint Disease Activity (DAS28), o Health Assessment Questionnaire (HAQ) e o nível de proteína C-reativa (PCR). Resultados: A duração média dos sintomas foi de 7,58 ± 3,59 meses. Foram encontradas correlações estatisticamente significativas (p < 0,05) entre os parâmetros de inflamação e a PCR no início do estudo e entre as mudanças nessas variáveis ao longo do estudo. Foram encontradas também correlações significativas (p < 0,05) entre o escore DAS28 e a PD e TN no início do estudo e entre as mudanças no escore DAS28 e PS e TN em todo o seguimento. Além disso, foram encontradas correlações significativas entre as mudanças no escore dos parâmetros de inflamação e no escore HAQ ao longo do seguimento. Conclusão: O sistema de escore US10 proposto provou ser uma ferramenta útil para monitorar a inflamação e o dano articular em pacientes com AR em fase inicial, demonstra correlações significativas com as alterações longitudinais na atividade da doença e no estado funcional.

Artritis reumatoide temprana: resultados clínicos y funcionales de una cohorte en un centro de alta complejidad, Cali-Colombia / Early rheumatoid arthritis: Clinical and functional outcomes of a cohort treated in a high complexity hospital, Cali-Colombia

La artritis reumatoide (AR) es una enfermedad crónica, inflamatoria, autoinmune y multisistémica, cuyo principal blanco es la membrana sinovial. El manejo adecuado y temprano mejora la evolución y pronóstico de la enfermedad. Objetivo: Evaluar los resultados clínicos y funcionales en pacientes con AR temprana. Metodología: Estudio observacional, con seguimiento longitudinal, de una cohorte de pacientes con AR temprana de menos de 12 meses de evolución, clasificados según los criterios de la Liga Europea Contra el Reumatismo y del Colegio Americano de Reumatología (ACR 2010). Se tuvieron en cuenta los criterios de remisión según la Escala de Actividad de la Enfermedad (DAS28-VSG) y el índice de actividad clínica de la enfermedad. Estado funcional según Cuestionario modificado de Evaluación de la Salud. Resultados: Se analizaron 99 pacientes. La edad promedio de los pacientes fue de 47,8 ± 15,5 años, el 93%(92) eran mujeres. Todos los pacientes fueron tratados con fármacos antirreumáticos modificadores de la enfermedad sintéticos. Durante el seguimiento a los 3 meses se observó una disminución significativa en los puntajes del DAS28y actividad clínica de la enfermedad respecto al valor en la visita basal (p <0,05). No se encontraron diferencias significativas en la evolución de pacientes diagnosticados antes y después de 3 meses desde el inicio de los síntomas (p>0,05). Conclusiones: Se evidencia mejoría sustancial de los pacientes con AR temprana tratados durante el primer año de inicio de los síntomas. El seguimiento continuo y periódico de la patología es una herramienta indispensable para evaluar el progreso de la enfermedad y hacer ajustes en el manejo terapéutico

Rheumatoid arthritis (RA) is a chronic, inflammatory, autoimmune multisystemic disease that affects the synovial joints. An appropriate and early management improves prognosis and course of the disease. Objective: To evaluate the clinical and functional outcomes of patients with RA. Methodology: Observational study with longitudinal follow up in a cohort of patients with early RA, with less than 12 months of evolution, classified according to the European League Against Rheumatism and American College of Rheumatology (ACR 2010) criteria. Remission criteria were taking into account according to Disease Activity Scale (DAS28-VSG), clinical activity disease index, and functional status according to Modified Health Assessment Questionnaire. Results: The analysis included 99 patients with a mean age of 47.8 + 15.5 years, and of which 92 (93%) were women. All patients were treated with synthetic disease-modifying antirheumatic drugs. At 3 months of follow-up, a significant decrease was observed in DAS28 scores and clinical activity disease index compared to the value at baseline values (p<.05). No significant differences were found between patients diagnosed before and after 3 months from onset of symptoms (p>.05). Conclusions: A substantial improvement was observed in patients with early RA treated during first year from onset symptoms. Continuous and periodic monitoring of the pathology is an indispensable tool for evaluating disease progress and making adjustments in the therapeutic management

Clinical value of transthyretin from patients with early rheumatoid arthritis / 实用医学杂志

Objective To investigate the clinical value of transthyretin (TTR) from patients with early rheumatoid arthritis (ERA). Methods 58 patients with ERA , 34 patients with later RA (LRA) and 34 healthy control (HC) were included in the research. TTR was analyzed by ELISA, whose variance was analyzed. TTR density, disease activity score28 (DAS28) score and rheumatoid factor (RF) were tested, and their correlation with TTR was analyzed. Results Serum level of TTR with ERA significantly increased compared with that with LRA and HC (P < 0.05), no statistical significance with LRA group and HC. TTR level was no correlation with the number of swelling and tender joints, disease activity score 28, RF, ESR, CRP, anti-cyclic citrylinated peptide antibody and anti-keratin antibodies, hemoglobin, thrombocyte and albumin. Conclusion Serum level of TTR significantly increased with ERA patients, contributing to early diagnosis for RA.

Epidemiological evaluation quality of life in patients suffering from early rheumatoid arthritis: a pragmatic, prospective, randomized, blind allocation controlled of a modular program group intervention / 한국역학회지

OBJECTIVES: Epidemiology has taken on new roles in the management of health care services. In this study, we developed a non-pharmacological self-management modular program group intervention and evaluated its efficacy as an adjunct therapy in patients suffering from early rheumatoid arthritis (RA). METHODS: Patients were randomized to either participate in a non-equivalent intervention group along with the standard of care or only receive standard-of-care treatment at a community rheumatology center. The outcomes measured were a pain visual analog scale (VAS), patient general health (GH) on a VAS, and the Short Form 36 Health Survey version 2 scale measuring quality of life. These parameters were evaluated in the first week to obtain baseline values, and at 20, 32, 48, and 60 weeks to evaluate the efficacy of the intervention group. RESULTS: The patients were randomized, with 100 patients in the intervention group and 106 in the control group. The intervention and control groups were similar with regard to the percentage of women (86% vs. 89.6%), tobacco usage (25% vs. 19.8%), mean age (42.6±13.2 years vs. 46.6±10.9 years), and disease duration (15.3±6.7 months vs. 14.5±6.6 months). The mean outcomes were significantly different between the two groups, and post-hoc pairwise analysis demonstrated significant deterioration in the control group in contrast to improvement in the intervention group at the second, third, fourth, and fifth evaluations. Improvements were often seen as early as the 12-week and 24-week follow-up visits. CONCLUSIONS: Epidemiology contributes to the evaluation of how well specific therapies or other health interventions prevent or control health problems. The modular program group intervention implemented in this study appears to be a suitable and feasible method to facilitate much more comprehensive management of early RA in socioeconomically challenged communities.

Vacinação em pacientes da Coorte Brasília de artrite reumatoide inicial / Vaccination in patients from Brasília cohort with early rheumatoid arthritis

Introdução: Os pacientes com diagnóstico de artrite reumatoide (AR) apresentam risco aumentado de infecções. A vacinação é uma medida preventiva recomendada. Não há estudos avaliando a prática da vacinação nos pacientes com AR inicial. Objetivos: Avaliar a frequência de vacinação e a orientação (feita pelo médico) sobre vacinas entre os pacientes com diagnóstico de AR inicial. Métodos: Estudo transversal incluindo pacientes da coorte Brasília de AR inicial. Foram analisados dados demográficos, índice de atividade da doença (Disease Activity Score 28 - DAS28), incapacidade funcional (Health Assessment Questionnaire - HAQ), dados sobre tratamento e vacinação após o diagnóstico da AR. Resultados: Foram avaliados 68 pacientes, sendo 94,1% mulheres, com idade média de 50,7 ± 13,2 anos. O DAS28 foi de 3,65 ± 1,64, e o HAQ de 0,70. A maioria dos pacientes (63%) possuía cartão vacinal. Apenas cinco pacientes (7,3%) foram orientados pelo médico sobre uso das vacinas. Os pacientes foram vacinados para tríplice viral (8,8%), tétano (44%), febre amarela (44%), hepatite B (22%), gripe (42%), influenza H1N1 (61,76%), pneumonia (1,4%), meningite (1,4%) e varicela (1,4%). Todos os pacientes vacinados com vírus vivo atenuado estavam em uso de imunossupressores e receberam as vacinas de forma inadvertida, sem orientação médica. Não houve associação entre o uso de nenhuma vacina e atividade da doença, incapacidade funcional, anos de escolaridade, hábitos de vida, comorbidades. Conclusão: Os pacientes foram pouco orientados pelo médico com relação ao uso das vacinas, com elevada frequência de vacinação inadvertida com componente vivo atenuado, enquanto a imunização com vírus ...

Introduction: Patients with a diagnosis of rheumatoid arthritis (RA) are at increased risk of infections. Vaccination is a recommended preventive measure. There are no studies evaluating the practice of vaccination in patients with early RA. Objectives: To evaluate the frequency of vaccination and the orientation (by the doctor) about vaccines among patients with early RA diagnosis. Methods: Cross-sectional study including patients from the early RA Brasilia cohort. Demographic data, disease activity index (Disease Activity Score 28 - DAS28), functional disability (Health Assessment Questionnaire - HAQ), and data on treatment and vaccination after diagnosis of RA were analyzed. Results: Sixty-eight patients were evaluated, 94.1% women, mean age 50.7 ± 13.2 years. DAS28 was 3.65 ± 1.64, and HAQ was 0.70. Most patients (63%) had vaccination card. Only five patients (7.3%) were briefed by the doctor about the use of vaccines. Patients were vaccinated for MMR (8.8%), tetanus (44%), yellow fever (44%), hepatitis B (22%), influenza (42%), H1N1 (61.76%), pneumonia (1.4%), meningitis (1.4%), and chickenpox (1.4%). All patients vaccinated with live attenuated virus were undergoing immunosuppressive therapy, and were vaccinated inadvertently, without medical supervision. There was no association between the use of any vaccine and disease activity, functional disability, years of education, lifestyle, and comorbidities. Conclusion: Patients were infrequently briefed by the physician regarding use of vaccines, with high frequency of inadvertent vaccination with live attenuated component, while immunization with killed virus was below the recommended level. .

Escore US7 modificado na avaliação de sinovite em pacientes com artrite reumatoide inicial / The modified US7 score in the assessment of synovitis in early rheumatoid arthritis

Objetivo: Avaliar o escore US7 modificado (escore MUS7 SIN) na avaliação de pacientes com artrite reumatoide inicial (ARI). Além disso, foram examinados recessos dorsais e palmares dos punhos, bem como pequenas articulações das mãos e dos pés, para o diagnóstico de sinovite, mediante uma avaliação global das articulações. Métodos: A amostra do estudo compreendeu 32 pacientes tratados para artrite, com 13 meses como duração média da doença. Foi utilizado um aparelho de ultrassonografia (US) com transdutor de alta frequência. As mãos dos participantes também foram radiografadas e analisadas pelo escore de Larsen. Resultados: Nas 832 articulações examinadas, detectou-se sinovite em 173 (20,79%), tenossinovite em 22 (4,91%) e erosões em três (1,56%). A sinovite foi predominantemente detectada no recesso dorsal (73,38%) das articulações MCF e IFP, quando comparado com o recesso palmar (26%). A presença de sinovite nas articulações avaliadas teve correlação com os resultados clínicos (HAQ-DI, DAS28), laboratoriais (anti-PCC, FR, PCR) e ultrassonográficos (r = 0,37 a r = 0,42; p = 0,04 a p = 0,003). Encontramos correlação do escore MUS7 SIN para US na técnica da escala de cinzas (gray scale) ou na técnica de Doppler de amplitude (power Doppler) com os valores do instrumento DAS28 (PCR) (r = 0,38; p = 0,0332) e com os resultados da PCR (r = 0,39; p = 0,0280), respectivamente. Conclusão: O recesso dorsal, o punho e as pequenas articulações podem ser considerados como locais importantes para a detecção de sinovite pelo escore MUS7 SIN em pacientes com ARI. .

Objective: To evaluate the modified US7 score (MUS7 score SYN) in the assessment of patients with early rheumatoid arthritis (ERA). In addition, dorsal and palmar recesses of the wrists as well as of small joints of the hands and feet were examined for the presence of synovitis by means of a global assessment of joints. Methods: The study sample comprised 32 patients treated for arthritis, with an average disease duration of 13 months. An ultrasound machine with high frequency transducer was used. Hands were also X-rayed and analysed by Larsen score. Results: Out of the 832 examined joints, synovitis was detected in 173 (20,79%), tenosynovitis in 22 (4,91%), and erosions in 3 (1,56%). Synovitis was predominantly detected in the dorsal recess (73,38%) of MCP and PIP joints, when compared with palmar recess (26%). The presence of synovitis in the joints evaluated correlated with clinical (HAQ-DI, DAS28), laboratory (ACPA, RF, CRP), and ultrasound results (r = 0,37 to r = 0,42; p = 0,04 to p = 0,003). We found correlation of the MUS7 score SYN of the gray scale US or of the power Doppler US with DAS28 (PCR) values (r = 0,38; p = 0,0332), and with CRP results (r = 0,39; p = 0,0280), respectively. Conclusion: The dorsal recess, the wrist, and small joints can be considered as important sites to detect synovitis by the MUS7 score SYN in patients with ERA. .

Diagnóstico por imagem da artrite reumatoide inicial / Imaging diagnosis of early rheumatoid arthritis

O diagnóstico precoce da artrite reumatoide é essencial para o manejo adequado da condição. Atualmente, considera-se que a fase inicial da doença constitui uma janela de oportunidade terapêutica para a artrite reumatoide. Embora o diagnóstico seja primordialmente clínico, o desenvolvimento e o aprimoramento de métodos laboratoriais e de imagem têm contribuído para o diagnóstico mais precoce e a determinação da conduta na artrite reumatoide inicial. Neste artigo os autores revisam o papel dos principais métodos de imagem utilizados para a avaliação da artrite reumatoide inicial, notadamente a radiologia convencional, a ultrassonografia e a ressonância magnética.

Early diagnosis of rheumatoid arthritis is essential for its proper management. Currently, the initial phase of rheumatoid arthritis is known to provide a window of therapeutic opportunity. Although the diagnosis is primarily clinical, the development and improvement of laboratory and imaging methods have contributed to earlier diagnosis and determination of procedures in early rheumatoid arthritis. In this article, the authors review the role of the major imaging methods used for assessing early rheumatoid arthritis, especially conventional radiography, ultrasonography, and magnetic resonance imaging.

Características laboratoriais de um grupo de pacientes com artrite reumatoide inicial / Laboratory characteristics of a cohort of patients with early rheumatoid arthritis

INTRODUÇÃO/OBJETIVO: Caracterizar uma população de pacientes com artrite reumatoide (AR) inicial quanto aos aspectos laboratoriais, comparando-a com outras coortes similares. PACIENTES E MÉTODOS: Os dados apresentados fazem parte de um estudo prospectivo de coorte incidente, em que foram avaliados 65 pacientes com AR inicial, acompanhados por 36 meses a partir do diagnóstico, na Clínica de Artrite Reumatoide Inicial do Hospital Universitário de Brasília (HUB). Foram registrados os dados demográficos, clínicos e laboratoriais pertinentes à avaliação inicial da coorte, incluindo hematimetria, provas de atividade inflamatória e presença de autoanticorpos (fator reumatoide - FR, anticorpos antipeptídeos citrulinados cíclicos - anti-CCP e antivimentina citrulinada - anti-Sa). RESULTADOS: Houve predomínio de mulheres (86 por cento), com média de idade de 45,6 anos. Doze pacientes (18,46 por cento) tiveram o diagnóstico laboratorial de anemia (hemoglobina < 12 g/dL). Velocidade de hemossedimentação (VHS) e proteína C reativa (PCR) encontravam-se acima do valor de referência em 51 (78,46 por cento) e 46 (70,76 por cento) pacientes, respectivamente. Trinta e dois indivíduos (49,23 por cento) foram positivos para pelo menos um dos isotipos de FR, sendo que 28 pacientes (43,07 por cento) foram positivos para FR IgA, 19 (29,23 por cento) para FR IgG e 32 (49,23 por cento) para FR IgM, respectivamente; 34 pacientes (52,30 por cento do total) foram positivos para pelo menos uma das técnicas utilizadas na averiguação de anti-CCP (CCP2, CCP3 ou CCP3.1), enquanto 9 (13,85 por cento) o foram para anti-Sa. CONCLUSÕES: As características laboratoriais dos pacientes acompanhados nessa coorte brasileira se assemelham em vários aspectos a coortes norte-americanas, europeias e latino-americanas anteriormente publicadas.

INTRODUCTION/OBJECTIVE: To characterize a population of patients with early rheumatoid arthritis (RA) according to laboratory aspects, comparing it with other similar cohorts. METHODS: Data presented are part of a prospective incident cohort study that evaluated 65 patients with early RA, followed for 36 months from the diagnosis at Early Rheumatoid Arthritis Clinic of Hospital Universitário de Brasília (HUB). We recorded demographics, clinical, and laboratory data relevant to the cohort initial assessment, including red blood cells, evidence of inflammatory activity, and presence of autoantibodies (rheumatoid factor (RF)), cyclic citrullinated peptide antibodies (anti-CCP), and antivimentin citrullinated (anti-Sa). RESULTS: There was a preponderance of female (86 percent) with mean age of 45.6 years. Twelve patients (18.46 percent) had laboratory diagnosis of anemia (hemoglobin < 12 g / dL). Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were above the reference value for 51 (78.46 percent) and 46 (70.76 percent) patients, respectively. Thirty-two patients (49.23 percent) were positive for at least one of the RF isotypes, and 28 patients (43.07 percent) were positive for IgA RF, 19 (29.23 percent) for IgG, and 32 ( 49.23 percent) for IgM RF, respectively; 34 patients (52.30 percent) were positive for at least one of the techniques used in investigation of anti-CCP (CCP2, or CCP3, or CCP3.1), while 9 (13,85 percent) were positive for anti-Sa. CONCLUSIONS: The laboratory characteristics of patients enrolled in this Brazilian cohort are similar in many respects to those of North-American, European, and Latin-American cohorts previously published.

Avaliação prospectiva da qualidade de vida em uma coorte de pacientes com artrite reumatoide inicial / Prospective evaluation of the quality of life in a cohort of patients with early rheumatoid arthritis

INTRODUÇÃO: Poucos estudos avaliaram, de forma prospectiva, os instrumentos de aferição de qualidade de vida, tanto genéricos quanto específicos, em pacientes com artrite reumatoide (AR) inicial. OBJETIVO: O objetivo deste trabalho foi caracterizar uma população de pacientes com AR inicial (menos de 12 meses de sintomas da doença no momento do diagnóstico) acompanhada prospectivamente quanto ao padrão de respostas aos questionários de qualidade de vida Health Assessment Questionnaire (HAQ) e o Medical Outcomes Study SF-36 Health Survey (SF - 36). PACIENTES E MÉTODOS: Foram avaliados 40 pacientes com diagnóstico de AR inicial no momento do diagnóstico, acompanhados prospectivamente por três anos, em uso de esquema terapêutico padronizado. Registrados os dados demográficos e clínicos e aplicados os questionários HAQ e SF-36 na avaliação inicial e aos 3, 6, 12, 18, 24 e 36 meses de acompanhamento. Comparações feitas pelo teste t de Student, t pareado e Wilcoxon (nível de significância de 5 por cento). RESULTADOS: A idade média foi de 45 anos e predominou o sexo feminino (90 por cento). A média do escore do HAQ inicial foi 1,89, com declínio progressivo até 0,77 no terceiro ano (P < 0,0001). A maioria dos elementos do SF-36 apresentaram significativa melhora durante os três anos de seguimento, com exceção de estado geral e vitalidade. CONCLUSÃO: Nessa população de pacientes com AR inicial no momento do diagnóstico, observou-se alterações importantes impacto na qualidade de vida no momento do diagnóstico, conforme avaliado pelos questionários HAQ e SF-36. O tratamento precoce da AR parece se associar à melhora da qualidade de vida relacionada com a saúde relatada pelo paciente.

INTRODUCTION: Few studies have prospectively assessed the tools used to measure quality of life, both generic and specific, in patients with early rheumatoid arthritis (RA). OBJECTIVE: The objective of this study was to characterize a population of patients with early RA (less than 12 months after symptom onset at the time of the diagnosis) prospectively followed for the pattern of responses to questionnaires addressing quality of life, the Health Assessment Questionnaire (HAQ) and Medical Outcomes Study SF-36 Health Survey (SF-36). PATIENTS AND METHODS: Forty patients with early RA at the time of diagnosis, treated with a standard treatment regimen, were prospectively followed for 3 years. Demographic and clinical data were recorded, and HAQ and SF-36 questionnaires were applied at baseline and after 3, 6, 12, 18, 24, and 36 months. Paired Student t test and Wilcoxon test were used for comparisons (significance level of 5 percent). RESULTS: The mean age was 45 years, with a prevalence of the female gender (90 percent). The average score of the initial HAQ was 1.89, with a progressive decline to 0.77 in the third year (P < 0.0001). Most domains of the SF-36 questionnaire presented significant improvement during the three years of follow-up, except for general health and vitality. CONCLUSION: In this population of patients with early RA at the time of diagnosis, the results showed significant impact on quality of life at the time of diagnosis, as measured by HAQ and SF-36 questionnaires. The early treatment of RA seems to be associated with improved health-related quality of life reported by patients.

Características demográficas e clínicas de uma coorte de pacientes com artrite reumatoide inicial / Demographic and clinical characteristics of a cohort of patients with early rheumatoid arthritis

INTRODUÇÃO: Há poucos estudos realizados com populações latino-americanas sobre as características demográficas e clínicas dos pacientes com diagnóstico de artrite reumatoide (AR) inicial. OBJETIVO: Caracterizar uma população de pacientes com AR inicial acompanhada, prospectivamente, quanto aos aspectos demográficos e clínicos, comparando-a com outras coortes similares. PACIENTES E MÉTODOS: Os dados apresentados fazem parte de um estudo prospectivo de coorte incidente, em que foram avaliados 65 pacientes com AR inicial, acompanhados de forma regular por 36 meses a partir do diagnóstico na Clínica de Artrite Reumatoide Inicial do Hospital Universitário de Brasília (HUB). Foram registrados os dados demográficos e clínicos pertinentes à avaliação inicial da coorte, incluindo características gerais, dados da história clínica e exame físico. Empregou-se estatística descritiva das variáveis analisadas. RESULTADOS: Houve predomínio de mulheres (86 por cento), com média de idade de 45,6 anos, brancas ou pardas (47,6 por cento), pertencentes à classe social média-baixa (53,85 por cento), com 8,3 anos de escolaridade em média. A maior parte dos pacientes iniciou os sintomas de forma aguda (76,9 por cento), com acometimento poliarticular (69,2 por cento), sinovite persistente em mãos (90,7 por cento) e rigidez matinal prolongada (157 minutos, em média). Os pacientes apresentaram uma contagem média de articulações dolorosas (18,6) e edemaciadas (13,9) elevada e alta prevalência de nódulos reumatoides (15,3 por cento), o que sugere doença de apresentação agressiva em sua fase inicial. CONCLUSÃO: As características demográficas e clínicas dos pacientes acompanhados nessa coorte brasileira divergiram em vários aspectos das coortes norte-americanas, europeias e latinoamericanas anteriormente publicadas.

INTRODUCTION: Very few studies carried out with Latin American populations on the demographic and clinical characteristics of patients diagnosed with early rheumatoid arthritis (RA) can be found in the literature. OBJECTIVE: To characterize a population of patients with early RA, prospectively followed, concerning demographic and clinical aspects and compare them with other similar cohorts. PATIENTS AND METHODS: The data presented are part of an incident cohort prospective study, in which 65 patients with early RA were evaluated and followed regularly for 36 months at the Early Rheumatoid Arthritis Outpatient Clinic of the University Hospital of Brasília (HUB, from the Portuguese). The demographic and clinical data of the initial evaluation, including general characteristics, clinical history, and physical examination were recorded. Descriptive statistics of the variables was applied. RESULTS: Women (86 percent) with a mean age of 45.6 years, Caucasian or Black (47.6 percent), belonging to intermediate-low social classes (53.85 percent), with 8.3 years of schooling, predominated. The presenting symptoms of the majority of patients were acute (76.9 percent), with polyarticular onset (69.2 percent), persistent synovitis of the hands (90.7 percent), and prolonged morning stiffness (157 minutes on average). Patients had a high average score of painful (18.6) and swollen (13.9) joints and high prevalence of rheumatoid nodules (15.3 percent), which suggests disease with aggressive presentation in its initial phases. CONCLUSION: The demographic and clinical characteristics of patients enrolled in this Brazilian cohort differed, on several aspects, from previously published North American, European, and Latin American cohorts.

Novos marcadores laboratoriais em artrite reumatoide inicial / New laboratory markers for early rheumatoid arthritis

O diagnóstico da artrite reumatoide é estabelecido considerando-se uma associação de achados clínicos. Nenhum teste laboratorial, achado histológico ou característica radiológica isoladamente confirma o diagnóstico. A avaliação na fase precoce da doença, contudo, é especialmente difícil, já que alterações sorológicas e radiológicas características muitas vezes estão ausentes. Alguns exames recentemente descritos, como a investigação dos anticorpos contra proteínas e peptídeos citrulinados, são especialmente úteis para o diagnóstico nas fases iniciais da doença. Outros marcadores, como exames genéticos, dosagem de marcadores do metabolismo ósseo e cartilaginoso, lecitina ligadora de manose, selectina E, leptina, interleucina 6 e marcadores de ativação do endotélio vascular, embora promissores, ainda não fazem parte dos recursos de investigação da rotina clínica.

The diagnosis of rheumatoid arthritis is established considering a combination of clinical findings. No laboratory test, histological finding or radiological feature alone confirm the diagnosis. The evaluation at the early phase of the disease, however, is especially difficult, since serological changes and radiological features are often absent. Some tests recently described, such as the investigation of antibodies against proteins and citrullinated peptides are particularly useful for diagnosing the early stages of the disease. Other markers, such as genetic tests, dosages of markers of the bone and cartilage metabolism, mannose-binding lecithin, E-selectin, leptin, interleukin 6 and activation markers of the vascular endothelium, although promising, are not yet part of the clinical investigation routine arsenal.

Distinct pattern of rheumatoid factor serotypes in serial evaluation of patients with early rheumatoid arthritis / Comportamento distinto dos sorotipos do fator reumatoide em avaliação seriada de pacientes com artrite reumatoide inicial

INTRODUÇÃO: O fator reumatoide (FR), apesar de suas limitações, ainda é o marcador sorológico mais utilizado para diagnóstico da artrite reumatoide (AR) inicial. Há controvérsias sobre sensibilidade, especificidade, correlação com prognóstico radiológico e variação ao longo do tempo dos títulos dos sorotipos IgG, IgM e IgA. OBJETIVO: Avaliar o comportamento dos diferentes sorotipos de FR (IgG, IgM e IgA), em avaliações seriadas, e sua correlação com a ocorrência de erosões radiográficas. PACIENTES E MÉTODOS: Foram avaliados 40 pacientes com o diagnóstico de AR inicial (menos de 12 meses de sintomas) durante três anos de acompanhamento. A titulação dos sorotipos de FR foi feita por ELISA, na avaliação inicial, e seriadamente ao longo de 36 meses. Aplicou-se um modelo de regressão de efeitos mistos, considerando-se como desfecho a ocorrência de erosões radiográficas (radiografia de mãos e punhos, pés e tornozelos anuais). RESULTADOS: Na avaliação inicial, 30 por cento, 42,5 por cento e 50 por cento dos pacientes foram positivos para FR IgG, IgA e IgM, respectivamente. Os títulos de FR IgA e FR IgM foram maiores nos pacientes que apresentaram erosões radiográficas durante o acompanhamento (10-220 UI/dL contra 0 a 10 UI/dL nos pacientes sem erosões, P < 0,05). Os títulos de FR IgM e IgG não variaram ao longo dos três anos de acompanhamento. Por outro lado, em relação aos títulos de FR IgA houve uma tendência linear positiva ascendente significativa (P = 0,0013) apenas no grupo que apresentou erosões radiográficas. CONCLUSÃO: 1) Pesquisa dos sorotipos FR IgA e FR IgG não aumenta a frequência de positividade do FR e, portanto, não contribui para o diagnóstico de AR; 2) a estabilidade observada do FR IgM ao longo do tempo não justifica solicitações repetidas do FR durante a evolução da AR; 3) títulos mais altos de FR IgA e FR IgM são observados nos pacientes mais graves, com erosões radiográficas; 4) FR IgA apresenta um comportamento claramente ...

INTRODUCTION: Rheumatoid factor (RF), despite its limitations, is still the most applied serological marker for diagnosis of early rheumatoid arthritis (RA). Sensitivity, specificity, correlation with prognosis and radiological progression, as well as variation over time of serotypes titers IgG, IgM and IgA, are yet controversial. OBJECTIVE: To evaluate the pattern of the different RF serotypes (IgG, IgM, and IgA) in serial evaluations during the first 36 months after RA diagnosis and their correlation with occurrence of radiographic erosions. PATIENTS AND METHODS: Forty patients with diagnosis of RA (less than 12 months of symptoms) were evaluated during 3 years of follow-up. Titers of RF serotypes were analyzed by ELISA at the initial evaluation and after 12, 24 and 36 months of follow-up. A mixed-effect regression model was applied, considering the presence of radiographic erosions as outcome (annual radiography of hands and wrists, feet and ankles). RESULTS: At the initial evaluation, 30 percent, 42.5 percent and 50 percent of the patients were positive for IgG, IgA and IgM RF, respectively. The titers of IgA and IgM RF were higher for patients who had radiographic erosions during the follow-up period (10-220 IU/dL versus 0 to 10 IU/dL in patients without erosions, P < 0,05). The titers of IgM and IgG RF remained unchanged over the three years of follow-up. On the other hand, there was a positive linear increasing trend for titers of IgA RF (P = 0.0013) only in the group with radiographic erosions. CONCLUSION: 1) Search of RF serotypes IgA and IgG does not increase the frequency of RF positivity and therefore it does not contribute to the RA diagnosis; 2) IgM RF stability observed over time does not justify repeated requests of RF during RA follow-up; 3) higher titers of IgA and IgM RF are observed in more severe patients, with radiographic erosions; 4) IgA RF presents a clearly distinct behavior in patients with or without radiographic ...

Frequency and Associated Factors of Generalized Bone Loss in Premenopausal Early Rheumatoid Arthritis / 대한류마티스학회지

OBJECTIVE: To investigate frequency and associated factors of generalized bone loss in patients with premeonpausal early rheumatoid arthritis (RA)who had not been treated with corticosteroid. METHODS: We measured bone mineral density (BMD)of lumbar spine and hip by dual energy X-ray absorptiometry (DEXA,Hologic QDR 4500)and investigated clinical;age,disease duration,numbers of tender and swollen joint,and laboratory;erythrocyte sedimentation rate (ESR),C-reactive protein (CRP)and rheumatoid factor (RF),variables in patients with premenopausal early RA who had not been treated with corticosteroid,consecutively.Generalized bone loss was defined as T score less than -1,and clinical and laboratory variables were analyzed for generalized bone loss. RESULTS: In 41 patients with premenopausal early RA (age;38 +/-8 years, duration of disease 8 +/-6 months),the frequency of generalized bone loss in lumbar spine and hip were 35%and 46%.In multivariate logistic regression analysis,elevated CRP level was significantly associated with generalized bone loss in lumbar spine and femur neck. CONCLUSIONS: In patients with premenopausal early RA,elevated CRP level was associated with generalized bone loss of lumbar spine and femur neck.

Radiological Feature and Significance of Hand X-Rayin Early Rheumatoid Arthritis / 대한내과학회지

OBJECTIVES: To evaluate the disease status in relation to the radiological findings of hands using some short term indices of disease activity and laboratory tests in early rheumatoid arthritis. METHOD: 136 patients with symptoms of rheumatoid arthritis for less than 2 years were studied by means of measuring erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, and anti-nuclear antibody. Of these, 71patients were performed the radiographies of hands at mean 1.3months after diagnosis. Also, 30 radiological films of hands were studied for measurement of intra- & inter-observer variations by well-trained rheumatologist and radiologist. All films were scored by the modified Sharps method. RESULTS: The radiological features of hands showed that the carpal bone was involved more common in the bony erosion (5.7%) and the joint space narrowing (8.8%), and the radiological progression in the interval of 24 months was positively correlated with the disease duration (p<0.05). Also, the radiological lesions and progressions appeared more severe in high disease activity, C-reactive protein (r : 0.334, p : 0.004) and Ritchie index (r : 0.249, p : 0.01) at diagnosis. On the other hand, they were correlated negatively with the age of disease onset (r : -0.357, p : 0.002). The Spearman correlations of inter- & intra-observer variations were significant by 0.716 and 0.775. CONCLUSION: The development of radiological lesions in early rheumatoid arthritis is closely correlated with the duration of disease. The patients with early rheumatoid arthritis who had active arthritis at the time of diagnosis showed more severe radiological progressions.