The Impact of the Off-site Monitoring Clinic (Virtual Monitoring Clinic) on the Practice of Outpatient Rheumatology in a Tertiary Centre during the COVID-19 Pandemic

The ongoing pandemic in Singapore is part of a global pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To control the spread of COVID-19 and prevent the healthcare system from being overwhelmed, 'circuit breaker' measures were introduced between 7 April and 1 June 2020 in Singapore. There is thus a crucial need for innovative approaches to the provision and delivery of healthcare in the context of safe-distancing by harnessing telemedicine, especially for patients with chronic diseases who have traditionally been managed in tertiary institutions. We present a summary of how the Virtual Monitoring Clinic has benefited the practice of our outpatient rheumatology service during the COVID-19 pandemic. The virtual consultations address the need for safe-distancing by limiting face-to-face appointments and unnecessary exposure of patients to the hospital where feasible. This approach ensures that the patients are monitored appropriately for drug toxicities and side-effects, maintained on good disease control, and provided with patient education.

Ressecção cirúrgica de calcinose sintomática em paciente com esclerose sistêmica / Surgical resection of symptomatic calcinosis in a patient with systemic sclerosis

Introdução: A esclerose sistêmica é uma doença rara, autoimune, com evolução progressiva, que afeta os tecidos conectivos e órgãos internos por inflamação, podendo causar calcinose de subcutâneo. Podem evoluir para quadros dolorosos e incapacitantes, podendo tornar-se infectados, principalmente quando ulceram pela pele. Objetivo: Apresentar caso de calcinose em região inguinal e sua evolução cirúrgica. Relato de Caso: Paciente feminina portadora de calcinoses em região inguinal bilateral, apresentando algia moderada/grave com falha de tratamento clínico. Realizada ressecção cirúrgica das calcinoses, que formavam cordões de fibrose com aderência na fáscia do músculo oblíquo externo. Realizado fechamento primário com nylon 2.0 pontos simples subdérmicos e ponto intradérmico continuo nylon 3.0 para fechamento estético e menor reação inflamatória. Boa evolução pós- operatório. Conclusão: O melhor tratamento da calcinoses ainda não é claro. O tratamento das complicações se torna essencial para reduzir a morbidade e aumentar a qualidade de vida do paciente.

Introduction: Systemic sclerosis is a rare, autoimmune, progressive disease that affects connective tissues and internal organs by inflammation, which can cause calcinosis cutis. It can progress to painful and disabling conditions, and can become infected, especially when skin ulceration is present. Objective: To present a case of calcinosis in the inguinal region and its surgical recovery. Case Report: A female patient with calcinosis in the bilateral inguinal region presenting with moderate/severe pain had a failed clinical treatment. We performed surgical resection of the calcinosis cutis, which had formed clusters of fibrosis with adhesion to the fascia of the external oblique muscle. We used simple nylon 2.0 sutures along the subdermal plane to perform primary closure and continuous nylon 3.0 sutures along the intradermal plane for aesthetic closure and minimal inflammatory reaction. Her postoperative recovery was positive. Conclusion: The best treatment for calcinosis cutis is still unclear. Treating complications becomes essential for reducing patients' morbidity and increasing their quality of life.

Capilaroscopia periungueal: relevância para a prática reumatológica / Nailfold capillaroscopy: relevance to the practice of rheumatology

A capilaroscopia periungueal é um método simples, de baixo custo, e de extrema relevância na avaliação de pacientes com fenômeno de Raynaud ou portadores de doenças do espectro da esclerose sistêmica (ES). Além de sua importância para o diagnóstico precoce da ES, constitui instrumento útil na identificação de pacientes esclerodérmicos com risco elevado para o desenvolvimento de complicações vasculares, viscerais e de óbito. A inclusão da capilaroscopia nos novos critérios para classificação da ES do Colégio Americano de Reumatologia (ACR) e da Liga Europeia Contra o Reumatismo (Eular) dá novo impulso para a utilização e disseminação do método. No presente artigo, pretendemos apresentar uma revisão didática, não sistemática, sobre o tema, com ênfase nos avanços recentemente descritos.

Nailfold capillaroscopy is a simple, low-cost method, that is extremely important in the evaluation of patients with Raynaud's phenomenon and of patients with systemic sclerosis (SSc) spectrum diseases. Besides its importance for the early diagnosis of SSc, nailfold capillaroscopy is a useful tool to identify scleroderma patients with high risk for development of vascular and visceral complications and death. The inclusion of capillaroscopy in the new classification criteria for SSc of the American College of Rheumatology (ACR) and European League Against Rheumatism (Eular) gives a new impetus to the use and dissemination of the method. In this paper, we present a didactic, non-systematic review on the subject, with emphasis on advances recently described.

Applications of systems approaches in the study of rheumatic diseases

The complex interaction of molecules within a biological system constitutes a functional module. These modules are then acted upon by both internal and external factors, such as genetic and environmental stresses, which under certain conditions can manifest as complex disease phenotypes. Recent advances in high-throughput biological analyses, in combination with improved computational methods for data enrichment, functional annotation, and network visualization, have enabled a much deeper understanding of the mechanisms underlying important biological processes by identifying functional modules that are temporally and spatially perturbed in the context of disease development. Systems biology approaches such as these have produced compelling observations that would be impossible to replicate using classical methodologies, with greater insights expected as both the technology and methods improve in the coming years. Here, we examine the use of systems biology and network analysis in the study of a wide range of rheumatic diseases to better understand the underlying molecular and clinical features.

Terapia médica actual en reumatología / Current medical therapy in rheumatology

El tratamiento médico de las enfermedades reumatológicas ha cambiado en forma importante en las últimas décadas. La aparición de los corticoides en 1948, la incorporación del metotrexato en la década del 90 y últimamente la utilización de medicamentos biológicos, han marcado los hitos más importantes en la historia de la especialidad. En este artículo se revisan los fármacos que actualmente se usan de manera regular en la práctica diaria.

Medical treatment of rheumatic diseases has changed significantly in recent decades. The appearance of steroids in 1948, the addition of methotrexate in the 90's and recently the use of biological drugs have marked important landmarks in the history of the specialty. This article reviews the drugs currently used regularly in daily practice.

Laboratorio en reumatología / Laboratory in rheumatology

La reumatología es una subespecialidad de la medicina interna que estudia y trata pacientes con problemas músculo esqueléticos, así como también enfermedades autoinmunes que comprometen el mesenquima y diferentes órganos, teniendo en común un rol patogénico del sistema inmune. El laboratorio juega un papel importante en el proceso diagnóstico de estas condiciones. Sin embargo, a pesar del progreso y refinamiento de algunos exámenes, la baja sensibilidad y especificidad que muchos de ellos tienen, hacen que la interpretación sea ocasionalmente muy difícil. En este artículo se revisan algunas características de los exámenes más comúnmente usados en reumatología, así como su sensibilidad y especificidad en el diagnóstico de estas enfermedades. Ya que la correcta interpretación de un examen requiere una compresión de conceptos estadísticos subyacentes, se revisan en forma muy somera algunos aspectos de ellos. Como conclusión, se remarca la necesidad de cuidar la interpretación de estos resultados, para evitar lo más que se pueda el costo económico, el stress psicológico y el problema médico derivado de la mala interpretación de estos exámenes.

Rheumatology is a medical subspecialty that takes care of some non traumatic musculoskeletal problems as well as many autoimmune diseases that involves the integuments and different organs, having as a common issue a pathogenic role of the immune system. Laboratory plays an important role in the diagnosis process of these conditions. However, despite the progress and refinement of some test, lack sensitivity and specificity makes interpretation of them occasionally quite difficult. Some characteristic, disease association as well as sensitivity and specificity are reviewed here for the most common rheumatic test. Since part of a correct interpretation of a test, needs an understanding of statistical principles underneath it, in a very simple way some of them are also considered in this review. As a conclusion, an underscoring of the need to process cautiously the rheumatic test results is made, to avoid as much as it can, unnecessary test and the burden both economically, psychological and medically an incorrect diagnosis, based on a misinterpretation of a test.

Estudios por imágenes en reumatismo / Imaging studies in reumatology

En reumatología los estudios por imágenes juegan un papel fundamental en el diagnóstico y seguimiento de los pacientes. Si bien la radiografía convencional es el examen de primera línea en el estudio, el desarrollo de técnicas como el Ultrasonido (US), la Resonancia Magnética (RM) y la Densitometría ósea posibilitan realizar diagnósticos en etapas más precoces, lo que permite modificar el curso de la enfermedad a través de tratamientos más tempranos y controlar en forma más precisa la respuesta al tratamiento. Los grandes avances tecnológicos de la última década han mejorado la calidad y cantidad de información que las distintas técnicas aportan, especialmente la RM; esto hace vislumbrar un cambio significativo en el diagnóstico por imágenes, ya que en el futuro no solo estará basado en los cambios morfológicos en órganos y tejidos; las imágenes obtenidas aportarán información bioquímica, molecular y fisiológica de los procesos patológicos facilitando su diagnóstico aún más precoz.

Imaging studies in Rheumatology play fundamental role in the patients diagnosis and follow-up. While conventional radiography is the first line examination, development of other techniques such as US, MRI and bone densitometry make possible earlier diagnosis which can modify the disease course through earlier treatment and controlling more precisely the response to it. The great technological advances of the last decade have improved the quality and quantity of information that different techniques provide, especially MRI, this makes glimpse a significant change in diagnostic imaging, since in the future not only will be based on the morphological changes in organs and tissues, the obtained images will provide biochemical, molecular and physiological information of the pathological processes, allowing earlier diagnosis.

Intervencionismo guiado por ecografía en reumatología / Ultrasound-guided intervention in rheumatology

Las aspiraciones e infiltraciones son procedimientos muy comunes en reumatología. La eficacia de ambos procedimientos depende de la posición correcta de la aguja dentro o alrededor del blanco elegido. Las intervenciones a ciegas con alta frecuencia son fallidas. La ultrasonografía (US) ha demostrado ser más eficaz y más segura como guía de procedimientos porque evita la lesión de estructuras nerviosas, tendinosas, óseas, etc., al facilitar observar la aguja hasta llegar al blanco. Dirigir una aguja por US hace que el procedimiento sea inocuo, de menor costo que la fluoroscopia o tomografía, con la posibilidad de acudir hasta la cama del paciente con los equipos portátiles. La terapia para infiltraciones no se reduce a los esteroides: actualmente se administra proloterapia, plasma rico en plaquetas, entre otros, para lesiones tendinosas con resultados alentadores. Otra de las ventajas del intervencionismo guiado por US es la realización de biopsias para el diagnóstico certero. En este artículo se hace una revisión de la técnica de infiltración de las diferentes regiones articulares y las ventajas que ofrece la US.

The aspirations and injections are common procedures in rheumatology. The efficacy of both procedures depends on the position of the needle within or around the chosen target. Blind interventions with high frequency are unsuccessful. Ultrasonography (U.S.) has proved more effective and safer procedures as a guide because in prevents injury to neural structures, tendon, bone, etc., to facilitate observing the needle to reach the target. U.S. direct needle makes the procedure is safe, lower cost than fluoroscopy or CT, with the possibility of going to the bedside with portable equipment. Therapy for infiltration is not limited to steroids, is currently given prolotherapy, platelet rich plasma for tendon injuries and others with encouraging results. Another advantage of U.S. interventionism is guided biopsies for diagnosis. In this article we review the technique of infiltration from the different regions and joint benefits of the U.S.

Perfil dos pacientes adultos atendidos em ambulatório de reumatologia em um hospital geral em Porto Alegre – RS / Characteristics of adult persons consulting in an outpatient rheumatology office in a general hospital in Porto Alegre – RS

Introdução: O conhecimento do perfil dos pacientes atendidos em um serviço médico é de fundamental importância para o planejamento de ações preventivas e curativas. As doenças reumáticas são reconhecidas pela cronicidade das queixas e grande morbidade que as acompanham, acarretando grande prejuízo em qualidade de vida e custo elevado para os sistemas de saúde. Objetivo: Verificar o perfil dos pacientes adultos atendidos no ambulatório de reumatologia do Complexo Hospitalar Santa Casa de Porto Alegre, RS. Métodos: Estudo ransversal descritivo, realizado através da aplicação de questionário na primeira consulta de pacientes atendidos no ambulatório de Reumatologia da Santa Casa, em período de seis meses. Resultados: Foram entrevistados 276 pacientes com média de idade de 52,5 anos, sendo 77,5% do sexo feminino e 56% procedentes de Porto Alegre. O tempo de ocorrência das queixas era de mais de um ano em 34,8% dos questionados, sendo que 12,7% tinham doença por tempo maior do que cinco anos. Trinta e quatro por cento dos pacientes já haviam buscado reumatologista previamente, sendo que 37,5% destes já haviam consultado cinco ou mais vezes pela mesma queixa. Médicos de outras especialidades foram procurados por 66%, sendo os traumatologistas os mais prevalentes (52%). Conclusão: Doenças articulares representam a segunda principal causa de incapacidade para o trabalho e o custo anual no atendimento desses pacientes repercute fortemente sobre os serviços de saúde. O investimento em políticas de saúde pública, com ações preventivas e curativas parte do conhecimento do perfil dos pacientes atendidos em determinado serviço de saúde.

Introduction: Knowledge of the profile of patients cared for at a medical service is critical for planning preventive and therapeutic strategies. Rheumatic diseases are known for the chronicity of complaints and associated high morbidity, leading to decreased quality of life for the patients and elevated costs for the health systems. Aim: To determine the profile of adults patients cared for at a rheumatology service of the Hospital Complex Santa Casa of Porto Alegre, RS. Methods: This is a descriptive cross-sectional study carried out through the application of a questionnaire responded by outpatients at their first visit to the above-mentioned rheumatology service during 6 months. Results: 276 patients (mean age = 52.5 years) were interviewed, of whom 77.5% were females and 56% lived in Porto Alegre. The reported beginning of complaints were older than one year among 34.8% of the sample, and 12.7% had the disease for longer than 5 years. 34% of the respondents had consulted with a rheumatologist in the past, and among these, 37.5% had already consulted five or more times because of the same complaint. Physicians of specialties other than rheumatology were consulted by 66% of the patients, traumatologists being the most prevalent ones (52%). Conclusion: Joint disorders are the second leading cause of disability for work, and the annual cost for caring for these patients exacts a heavy toll from health systems. The investment in public health policies, with preventive and therapeutic strategies, should start from knowledge of the profile of patients cared for at a particular health service.

Medical arthroscopy--emerging era of rheumatological intervention.

OBJECTIVE: To evaluate the safety and diagnostic value of arthroscopy performed by a rheumatologist. METHODS: Decisions for performing arthroscopy were taken when detailed clinical history-and relevant rheumatological investigations failed to arrive at a definite diagnosis. Arthroscopies were performed under local anesthesia as a daycare procedure. Synovial biopsies taken during procedures were subjected to histopathological examination (HPE). RESULTS: Of the 50 patients enrolled, 39 were males while 11 were females with mean age of 35.5 years. In lower limb oligoarthritis group of patients, three had macroscopic picture of crystal arthropathy, rest of the 29 patients revealed gross picture indicative of non-specific synovitis. While in polyarticular group of eight patients, three had macroscopic picture suggestive of crystal arthropathy (probably polyarticlar gout) while five were indicative of rheumatoid arthritis. In monoarticular disease pattern (n= 10) macroscopic picture findings were as follows- crystal arthropathy-two, tubercular-three, synovial chondromatosis-one and non-specific synovitis-two. HPE of synovium did not correlate in many cases. CONCLUSION: Arthroscopy using a 4 mm scope under local anesthesia in the hands of rheumatologists is a safe daycare procedure. In few cases arthroscopy helped in arriving at a final diagnosis but many patients remained undiagnosed. Both the rheumatologists and the pathologists require further experience in this field.

Utilization characteristics of health care service for rheumatoid arthritis patients in Korea

The purpose of this study was to determine the factors which were responsible for delaying early diagnosis and optimal management of rheumatoid arthritis (RA) in Korea. We interviewed 109 outpatients diagnosed as RA being treated by rheumatologists, and we eventually analyzed 98 patients' data. The median length of time from symptom onset to the first visit to a medical doctor, to diagnosis, and visiting a rheumatologist were 8 weeks, 23 weeks, and 42 months respectively. The subspecialist with whom the patients consulted with for the longest time before visiting a rheumatologist were an orthopaedic surgeon for 51 patients, a Chinese herbal doctor for 19 patients, and a pharmacist for 16 patients. For early diagnosis and optimal management of RA in Korea, we believe that it is necessary to reduce the use of unconventional medical services such as Chinese herbal medicine and nonprescribed medication, and to emphasize rheumatologic and rehabilitative care in the early stage.