Prevalence of psoriatic arthritis in Chinese population with psoriasis: A multicenter study conducted by experienced rheumatologists / 中华医学杂志(英文版)

BACKGROUND@#Reports on the prevalence of psoriatic arthritis (PsA) among Chinese patients with psoriasis are very limited. This study, conducted by rheumatologists, estimated the prevalence of PsA in a large number of Chinese patients with psoriasis.@*METHODS@#Consecutive patients with a confirmed diagnosis of psoriasis attending nine dermatology clinics in five hospitals were recruited. All psoriasis patients were asked to complete a questionnaire comprising 16 questions to identify possible cases of PsA. All patients with one or more positive answers to the questionnaire were evaluated by two experienced rheumatologists.@*RESULTS@#A total of 2434 psoriasis patients, including 1561 males and 873 females, were enrolled. Both the questionnaire and rheumatologists' examinations were completed in the dermatology clinics. The results identified 252 patients with PsA, comprising 168 males and 84 females. The overall prevalence of PsA among psoriasis patients was 10.4% (95% confidence interval [95% CI], 9.1%-11.7%). By sex, the prevalence was 10.8% (95% CI, 9.2%-12.5%) for males and 9.6% (95% CI, 7.7%-11.9%) for females and there was no significant sex difference in the prevalence of PsA (P = 0.38). Of the 252 PsA patients, 125 (49.6%, 95% CI, 41.3%-59.1%) were newly diagnosed by rheumatologists. Consequently, the prevalence of undiagnosed PsA among psoriasis patients was 5.2% (95% CI, 4.4%-6.2%).@*CONCLUSION@#The prevalence of PsA in the Chinese population with psoriasis is about 10.4%, which is almost double that of previous reports in the Chinese population, but lower than that in Caucasians.

Uso de medicina complementaria y alternativa y su asociación con la relación médico-paciente en enfermos con artritis reumatoide / Association between physician-patient relationship and the use of complementary and alternative medicine in patients with rheumatoid arthritis

RESUMEN Introducción: El uso de medicina complementaria y alternativa (MCA) en pacientes con enfermedades reumáticas es prevalente pero la comunicación con el reumatólogo suele ser deficiente, lo cual afecta la relación médico-paciente (RMP). Objetivos: Evaluar la asociación entre el uso de MCA y la RMP en enfermos con artritis reumatoide. Como objetivos adicionales, describir la percepción del paciente sobre la comunicación con su reumatólogo respecto al uso de MCA y el patrón de uso de las diferentes modalidades terapéuticas. Materiales y métodos: Estudio descriptivo de corte transversal. El uso de MCA y la RMP se evaluaron mediante la autoaplicación de cuestionarios validados (I-CAM-Q y PDRQ-9 respectivamente). Resultados: Se incluyó a 246 pacientes ambulatorios de una institución de tercer nivel de atención. Se encontró asociación entre una mayor satisfacción con el tratamiento y el no usar MCA, y entre el hecho de informar al reumatólogo sobre el uso de MCA con un mayor grado de acuerdo con el médico sobre el origen de los síntomas y mayor satisfacción con el tratamiento. Las modalidades más frecuentemente utilizadas fueron: quiropraxia, acupuntura y productos herbales. El 78,5% afirmaron estar de acuerdo con comunicar el uso de este tipo de medicación al reumatólogo, sin embargo, solo el 31,3% lo notificó, por temor a represalias (54,4%). Conclusiones: Pese a la alta prevalencia de uso de MCA en nuestros pacientes, la mayoría no lo comunicó al reumatólogo. Se encontró asociación entre el uso de MCA y una menor satisfacción del paciente con el tratamiento y entre la comunicación médico-paciente sobre la práctica de MCA y una mejor satisfacción con el tratamiento.

ABSTRACT Introduction: Although complementary and alternative medicine (CAM) use among patients with rheumatic diseases is extensive, discussions regarding these treatments occur rarely in the rheumatology setting, directly affecting the physician-patient relationship (PPR). Objectives: The aim of this study was to evaluate the association between patient-physician relationship and complementary and alternative medicine use. As secondary objectives, to describe the patient's perspective towards CAM use and estimate the prevalence of CAM treatments used in patients with rheumatoid arthritis. Methods and materials: A descriptive cross-sectional survey was conducted, in which CAM use and physician-patient relationship were assessed by self-reported validated questionnaires (I-CAM-Q and PDRQ-9, respectively). Results: The study included a total of 246 outpatients of a tertiary care hospital. There were no significant differences between CAM users vs. non-users, or informers vs. non-informers in terms of physician-patient relationship measured by PDQR. The most frequent used CAM treatments were: chiropractice, acupuncture, and herbal products. A large majority (78.5%) of the patients expressed agreement to the discussion of CAM use with the rheumatologist, but only 31.3% of total CAM users did so because of fear of retaliation (54.4%). Conclusion: Despite the extensive practice of CAM among patients with rheumatoid arthritis, most patients did not discuss these treatments with their physicians. Associations were found between MCA use and a lower patient's treatment satisfaction and between physician-patient communication about CAM practice and a higher patient's treatment satisfaction.

Variación en la definición del examen articular para la clinimetría de la artritis reumatoide: resultados de una encuesta realizada a un grupo de reumatólogos colombianos / Variation in the definition of the examination of joints in rheumatoid arthritis: Results of a survey conducted on a group of Colombian rheumatologists

RESUMEN Introducción: En el seguimiento de los pacientes con artritis reumatoide (AR) el examen articular (determinar el número de articulaciones dolorosas e inflamadas) es la piedra angular para determinar la actividad. El objetivo del estudio fue conocer la opinión de un grupo de reumatólogos acerca del examen articular de los pacientes con AR al definir la articulación tumefacta o dolorosa y, de la misma manera, evaluar la variación en el examen articular entre los participantes. Métodos: Se aplicó un cuestionario, desarrollado por los autores, a un grupo de reumatólogos para explorar aspectos generales y específicos al examinar cada una de las articulaciones, además de conceptos de las definiciones de dolor y de inflamación en el examen físico. Resultados: El 78% de los entrevistados consideró que todos los aspectos eran importantes, como evaluar la movilización pasiva de la articulación, explorar el dolor a la palpación y el dolor espontáneo. El 53,8% consideró la movilidad pasiva sin que haya dolor o edema articular a la palpación. El 62,6% estaba de acuerdo con realizar la presión hasta cuando comienza a palidecer el lecho ungular del dedo del examinador. En el momento de palpar el margen articular para determinar la inflamación, el 55% estuvo de acuerdo y el 14,3% no estuvo seguro. Para el 47,2% eran importantes el derrame articular, la fluctuación y la alteración del rango del movimiento para definir la inflamación en el examen articular. Cerca de las tres cuartas partes estuvo de acuerdo con la técnica de las articulaciones temporomandibular, acromioclavicular, esternoclavicular, hombro y tobillo. Se evidenció que pocos estaban de acuerdo con la técnica en la articulación de la cadera. Al preguntarse por más de una técnica en algunas articulaciones, como las MCF (57,1%) y del tarso medio (45%), el porcentaje de los que estuvieron de acuerdo con una de las 2 técnicas disminuyó. Discusión: Al parecer no existe un método de examen formal, ya que hubo diferentes opiniones en las técnicas propuestas. Esto puede ser crítico, ya que el examen articular es la base de la clinimetría de la AR. Un porcentaje importante del grupo no estuvo de acuerdo o seguro acerca de algunos conceptos sobre componentes del examen, lo que denota una variación en los conceptos y esto podría llevar a la mala clasificación de los pacientes al determinar la actividad de la enfermedad, lo que impactaría en la estrategia T2T o treat to target. Conclusión: Existió una gran variación en la opinión acerca de los conceptos relacionados con el examen articular del paciente que padece AR al definir articulaciones tumefactas o dolorosas, por lo que se recomienda a futuro un proceso de estandarización como la mejor alternativa.

ABSTRACT Introduction: In the follow-up of rheumatoid arthritis (RA) patients, the physical examination of the joints in order to determine the number of painful and swollen joints is the corners-tone for determining activity. The objective of this study was to find out the opinion of a group of rheumatologists as regards the examination of joints of patients with RA to define the swollen or painful joint. At the same time an evaluation was made on the variation in the joints examination between the participants. Methods: A questionnaire was administered to a group of rheumatologists in order to determine general issues and examining each of the joints, as well as concepts of definitions of pain and inflammation in the joints. Results: The majority of the participants (78%) stated that all aspects were important, such as evaluating passive joint mobilisation, pain to palpation, and spontaneous pain. Passive mobility without having pain or swollen joint tenderness was said to be important by 53.8% of the participants, and 62.6% agreed with observing the pressure exerted by the examiner until the nail bed of the finger started to turn pale. As regards touching the margin of joint to determine swelling, 55% agreed, and 14.3% were not sure. Synovial effusion, fluctuation, and the alteration in the range of motion to define inflammation in the examination of joint were important for 47.2% of the examiners. Almost three-quarters agreed with the temporomandibular, acromioclavicular, sternoclavicular, shoulder and ankle joint technique. It was obvious that few were in accordance with the technique in the hip joint. When asked about more than one technique in some joints such as the MCF (57.1%) and mid-tarsal (45%) joints, there was a decrease in the percentage of those who agreed with one of the 2 techniques. Discussion: Apparently, there is no standard joint assessment method, since there were different opinions in the techniques proposed. This could be critical since examination of joints is the basis of the clinimetric examination in RA. A significant percentage of the group did not agree or were unsure of some components of the examination. This could lead to a variation in the concepts and a misclassification of patients in order to determine the activity of RA. This would also have an impact on the T2T or treat to target strategy. Conclusion: There was a wide variation in opinions about the concepts related to the examination of joints, such as defining swollen or painful joints in patients suffering RA. This requires a process of standardisation as the best recommended alternative.

Abordaje práctico de la espondiloartritis / Practical approach to spondyloarthritis

Introducción: la espondiloartritis, es una forma de artritis inflamatoria que, generalmente comienza entre los 17 y los 45 años. La inflamación sistémica es una característica clave que ayuda a distinguirla de otros tipos de artritis, incluida la artritis por desgaste y desgarro, como la osteoartritis. Objetivo: brindar información sobre el abordaje práctico de la espondiloartritis para contribuir a esclarecer puntos que, a juicio de los autores de este trabajo, son importantes para el manejo de la misma. Desarrollo: en poco tiempo han tenido lugar inusitados avances que abarcan todos los aspectos de su manejo, incluidos el diagnóstico y el seguimiento, pero sobre todo en su tratamiento. Algunas presentaciones engañosas son propias del comienzo retardado, como la espondiloartritis periférica de inicio tardío (LOPS), que se caracteriza por una oligoartritis inflamatoria que contrasta con los signos generales, un importante síndrome inflamatorio y, a veces, edema asimétrico de las extremidades inferiores. Conclusiones: el papel de los reumatólogos es esencial en el manejo de esta enfermedad, pues son los especialistas mejor calificados para tener a su cargo a estos pacientes, mientras que los generalistas participan más en la detección de la misma(AU)

Introduction: spondyloarthritis, or SpA, is a form of inflammatory arthritis that usually begins between 17 and 45 years. Systemic inflammation is a key feature that helps distinguish it from other types of arthritis, including arthritis by tearing and tearing, such as osteoarthritis. Objective: to provide information on the practical approach of spondyloarthritis to help clarify points that, in the opinion of the authors of this work, are important for the management of it. Development: in a short time, there have been unusual advances that cover all aspects of its management, including diagnosis and monitoring, but especially in its treatment. Some deceptive presentations are typical of delayed onset, such as late-onset peripheral spondyloarthritis (LOPS), which is characterized by an inflammatory oligoarthritis that contrasts with the general signs, an important inflammatory syndrome and, sometimes, asymmetric edema of the lower extremities. Conclusions: the role of rheumatologists is essential in the management of this disease, as they are the best qualified specialists to be in charge of these patients, while the generalists participate more in the detection of it(AU)

Anestesia, analgesia, reumatología y alivio del dolor agudo y crónico / Anesthesia, analgesia, rheumatology and relief of acute and chronic pain

Introducción: el tratamiento eficaz del dolor postquirúrgico es hoy un reto para los anestesistas, reumatólogos, traumatólogos, cirujanos e investigadores de diversas especialidades, quienes proponen constantemente protocolos que toman como base a la evidencia científica. Objetivo: reflexionar y abrir el debate respecto al rol de la anestesia en el alivio del dolor de origen reumatológico. Desarrollo: en Reumatología, se recomienda, en todo paciente con dolor reumático crónico, calcular la intensidad del dolor, tanto para la elección primera del tratamiento analgésico como para la medición de la respuesta. Y, para ello, se han propuesto varios métodos de cuantificación. Conclusiones: el manejo diagnóstico y el tratamiento multidisciplinario presiden cuando se examina a este tipo de casos, ya que es la única manera de identificar el origen del dolor y suministrar un alivio prudente. En su generalidad, los pacientes responden al tratamiento conservador y solo un exiguo grupo va a necesitar de técnicas anestésicas invasivas(AU)

Introduction: The effective treatment of postoperative pain is today a challenge for anesthetists, rheumatologists, orthopedic surgeons, surgeons and researchers of various specialties, who constantly propose protocols based on scientific evidence. Objective: Reflect and open the debate regarding the role of anesthesia in the relief of pain of rheumatological origin. Development: In Rheumatology, it is recommended, in all patients with chronic rheumatic pain, to calculate the intensity of the pain, both for the first choice of the analgesic treatment and for the measurement of the response. And, for this, several methods of quantification have been proposed. Conclusions: Diagnostic management and multidisciplinary treatment preside when this type of case is examined, since it is the only way to identify the origin of pain and provide prudent relief. In general, patients respond to conservative treatment and only a small group will need invasive anesthetic techniques(AU)

Recommendations from the Brazilian society of rheumatology for the diagnosis of Sjögren's syndrome (Part I): glandular manifestations (systematic review)

Abstract Background: Primary Sjögren's syndrome (pSS) is a systemic immune-mediated disease whose main characteristic is exocrine gland inflammation and, subsequent reduction in tear and saliva production. A delayed diagnosis is common due to the nonspecific clinical manifestations of disease. The aim of the present study was to develop recommendations for the diagnosis of glandular manifestations of pSS based on evidence and expert opinion. Main body of the abstract: We conducted a systematic literature review to retrieve the best evidence available on the accuracy of diagnostic tests for pSS. We also held two in-person meetings with experts (rheumatologists, pathologists, ophthalmologists and dentists) to establish their level of agreement using the Delphi method. Ultimately, we generated 18 recommendations that aim to facilitate the diagnosis of the glandular manifestations of pSS. Conclusion: The diagnosis of glandular manifestations of pSS is complex and multidisciplinary. It requires specific knowledge in the field of ophthalmology, immunology, pathology and imaging, making it compulsory for the rheumatologist to work with professionals from these different areas in order to improve accuracy and early diagnosis. Glandular dysfunction tests, ANA, RF, Anti-Ro, protein electrophoresis, urinalysis, blood count, C-Reactive protein, complement, testing for syphilis and viruses (HCV, HIV) and SGUS should be investigated when dryness or systemic manifestation are present. Minor salivary gland biopsy is recommended for all anti-Ro negative or incomplete criteria cases.

Development of rheumatology training in Brazil: the option for a medical residency program / Evolução da formação de reumatologistas no Brasil: a opção pela residência médica

Abstract Objective To describe the characteristics and progression of the supply of new rheumatologists in Brazil, from 2000 to 2015. Methods: Consultations to databases and official documents of institutions related to training and certification of rheumatologists in Brazil took place. The data were compared, summarized and presented descriptively. Results: From 2000 to 2015, Brazil qualified 1091 physicians as rheumatologists, of which 76.9% (n = 839) completed a medical residency program in rheumatology (MRPR); the others (n = 252) achieved this title without MRPR training. There was an expansion of MRPR positions. At the same time, there was a change in the profile of the newly qualified doctors. Early in the series, the fraction of new rheumatologists without MRPR, entering the market annually, was approaching 50%, dropping to about 15% in recent years. In 2015, Brazil offered 49 MRPR accredited programs, with 120 positions per year for access. There was an imbalance in the distribution of MRPR positions across the country, with a strong concentration in the southeast region, which in 2015 held 59.2% of the positions. Public institutions accounted for 94% (n = 789) of graduates in MRPR during the study period, while still maintaining 93.3% (n = 112) of seats for admission in 2015. Conclusions: In the last sixteen years, in parallel with the expansion of places of access, MRPR has established itself as the preferred route for rheumatology training in Brazil, mainly supported by public funds. Regional inequalities in the provision of MRPR positions still persist, as challenges that must be faced.

Resumo Objetivo: Descrever as características e a evolução da oferta de novos reumatologistas no Brasil, de 2000 a 2015. Métodos: Fizeram-se consultas a bases de dados e a documentos oficiais de instituições relacionadas à formação e à certificação de reumatologistas no país. Os dados foram cruzados, sumarizados e apresentados de forma descritiva. Resultados: De 2000 até 2015, o Brasil habilitou 1.091 médicos à condição de reumatologistas, dentre os quais 76,9% (n = 839) concluíram residência médica em reumatologia (RMR); os demais (n = 252) obtiveram o título sem cursar RMR. Houve expansão das vagas de RMR. Paralelamente, ocorreu uma modificação no perfil dos recém-habilitados. No início da série, a fração de novos reumatologistas sem RMR, ingressantes no mercado anualmente, aproximava-se dos 50%, reduziu-se para cerca de 15%, em anos recentes. Em 2015, havia no país 49 programas de RMR credenciados, com 120 vagas anuais de acesso. Observou-se desequilíbrio na distribuição de vagas de RMR pelo país, com forte concentração na Região Sudeste, que em 2015 detinha 59,2% das vagas. Instituições públicas responderam por 94% (n = 789) dos concluintes de RMR no período estudado, mantiveram ainda 93,3% (n = 112) das vagas para ingresso em 2015. Conclusões: Nos últimos 16 anos, paralelamente à expansão das vagas de acesso, a RMR consolidou-se como via preferencial para formação em reumatologia no Brasil, eminentemente suportada por recursos públicos. Desigualdades regionais na oferta de vagas de RMR persistem como desafios a serem enfrentados.

Interventional rheumatology: the competence of Brazilian rheumatologists / Reumatologia intervencionista: competência dos reumatologistas brasileiros

Abstract Objectives: Describe Brazilian rheumatologists's competence in interventional rheumatology; assess the association between this ability and demographic and training variables. Methods: A cross-sectional study with 500 Brazilian rheumatologists. Participants were assessed by self-administered questionnaire consisting of demographics, training, practice in office and knowledge in interventional rheumatology data. Results: 463 participants had their data analyzed. The mean age was 40.2 years (±11.2). 70% had performed periarticular injections and 78% had performed intra-articular injections. The sample was divided into three groups: non-interventionist, little interventionist and very interventionist. The non-interventionist group showed (p < 0.001-0.04) higher mean age, lower proportion of university bond, lower training history, higher proportion of graduates in the Southeast country, and higher proportion of graduates in the 1980s to 1989. The very interventionist group showed higher (p < 0.001-0.018) proportion of adult rheumatologists, higher proportion of university bond, longer training time with greater practice of complex procedures, and higher proportion of graduates, trained and with private practice in the South country. Variables most associated with the very interventionist subgroup are performing axial intra-articular injections (OR: 7.4, p < 0.001), synovial biopsy (OR: 5.75, p = 0.043), image-guided IAI (OR: 4.16, p < 0.001), viscosupplementation (OR = 3.41, p < 0.001), joint lavage (OR = 3.22, p = 0.019), salivary gland biopsy (OR = 2.16, p = 0.034) and over 6-month training (OR: 2.16, p = 0.008). Conclusions: Performing more complex invasive procedures and over 6-month training in interventional rheumatology were variables associated with enhanced interventional profile.

Resumo Objetivos: Descrever a competência dos reumatologistas brasileiros na reumatologia intervencionista (RI); avaliar a associação entre essa capacidade e variáveis demográficas e de treinamento. Métodos: Fez-se um estudo transversal com 500 reumatologistas brasileiros. Os participantes foram avaliados por questionário autoadministrado, constituído por dados demográficos, treinamento, prática em consultório e conhecimento em dados de RI. Resultados: Analisaram-se os dados de 463 participantes. A média foi de 40,2 anos (± 11,2). Desses, 70% fizeram injeções periarticulares (IPA) e 78% intra-articulares (IIA). A amostra foi dividida em três grupos: não intervencionista, pouco intervencionista e muito intervencionista. O grupo não intervencionista apresentou (p < 0,001 - 0,04) maior média de idade, menor proporção de vínculo universitário, menor história de treinamento, maior proporção de graduados na Região Sudeste do país e maior proporção de graduados nas décadas de 1980 a 1989. O grupo muito intervencionista apresentou (p < 0,001 - 0,018) maior proporção de reumatologias que atendem pacientes adultos, maior proporção de vínculo universitário, maior tempo de treinamento de prática de procedimentos complexos, maior proporção de graduados no sul do país, treinados e com consultório particular nessa região. As variáveis mais frequentemente associadas ao subgrupo muito intervencionista foram realização de IIA axial (OR: 7,4, p < 0,001), biópsia sinovial (OR: 5,75, p = 0,043), IIA guiada por imagem (OR: 4,16, p < 0,001), viscossuplementação (OR = 3,41, p < 0,001), lavagem articular (OR = 3,22, p = 0,019), biópsia da glândula salivar (OR = 2,16, p = 0,034) e mais de seis meses de treinamento (OR: 2,16; p = 0,008). Conclusões: Fazer procedimentos invasivos mais complexos e ter mais de seis meses de treinamento em RI foram as variáveis associadas a um maior perfil intervencionista.

Performance and agreement between classification criteria and rheumatologist's diagnosis of the most widely used SpA classification criteria in a Colombian group of patients with chronic low back pain / Acuerdo entre los criterios más utilizados para la clasificación de las espondiloartritis (SpA) y el diagnóstico clínico hecho por un reumatólogo experto en un grupo de pacientes jóvenes con dolor lumbar coránico

Abstract Objective: To evaluate the performance of the most widely used SpA classification criteria in a Colombian group of patients with chronic low back pain. Methods: We assessed the ASAS and the European Spondyloarthropathy Study Group (ESSG) classification criteria in a group of 133 patients who attended consecutively over a period of six months at outpatient clinic of low back pain. All the patients were evaluated with the same protocol. The patients were divided into two groups according to the diagnosis. The diagnosis was compared with the diagnosis made by a expert rheumatologist blinded to patient information. Results: 81 patients with SpA and 52 with other diagnoses were included. There were no differences in age and age of onset of symptoms between the two groups. The SpA group included 55 males and more common clinical findings were: enthesitis, arthritis, sacroiliitis, HLA-B27-positive, previous infection, and dactylitis. The sensitivity and specificity of criteria were: ASAS criteria 96% of sensibility and 80% of specificity, and ESSG criteria 95% and 100% respectively. The agreement between the classification criteria and the diagnosis established by the rheumatologist showed a Cohen's kappa index of 0.938 for ESSG criteria (95% CI: 0.877-0.998) and 0.790 for the ASAS criteria (95% CI: 0.682-0.898). Conclusion: In a Colombian group of SpA patients, the new ASAS classification criteria have a good concordance with clinical diagnosis but are not superior to the ESSG criteria.

Resumen Objetivo: Evaluar el acuerdo entre los criterios de clasificación para SpA y el diagnóstico de un experto reumatólogo en un grupo de pacientes con dolor lumbar. Métodos: Se evaluó el comportamiento de los criterios de ASAS y del ESSG en 133 pacientes que acudieron de forma consecutiva durante seis meses a la clínica ambulatoria de dolor lumbar. Todos los pacientes se evaluaron con el mismo protocolo. Los pacientes fueron divididos en dos grupos de acuerdo con el diagnóstico. Posteriormente se estableció del acuerdo diagnóstico con el de un experto reumatólogo ciego a la información previa de los pacientes. Resultados: 81 pacientes con SpA y 52 con otros diagnósticos fueron incluidos. No hubo diferencias en la edad y la edad de aparición de los síntomas. El grupo SpA incluyó a 55 varones y los hallazgos más comunes fueron: entesitis, artritis, sacroileitis, infección previa, HLA-B27, y dactilitis. La sensibilidad y especificidad de los criterios fueron: ASAS 96% de sensibilidad y 80% de especificidad, y ESSG 95% y 100% respectivamente. El acuerdo entre los criterios de clasificación y el diagnóstico del reumatólogo mostró un índice kappa de 0,938 con criterios ESSG (IC del 95%: 0,877-0,998) y 0,790 para los criterios ASAS (IC del 95%: 0,682-0,898). Conclusión: En un grupo de pacientes colombianos SpA, los nuevos criterios de clasificación ASAS tienen una buena concordancia con el diagnóstico clínico, pero no son superiores a los criterios ESSG.

Incidence and prevalence of systemic sclerosis in Campo Grande, State of Mato Grosso do Sul, Brazil / Incidência e prevalência de esclerose sistêmica em Campo Grande, Estado de Mato Grosso do Sul, Brasil

Abstract Introduction: Systemic sclerosis is an autoimmune disease which shows extreme heterogeneity in its clinical presentation and that follows a variable and unpredictable course. Although some discrepancies in the incidence and prevalence rates between geographical regions may reflect methodological differences in the definition and verification of cases, they may also reflect true local differences. Objectives: To determine the prevalence and incidence of systemic sclerosis in the city of Campo Grande, state capital of Mato Grosso do Sul (MS), Brazil, during the period from January to December 2014. Methods: All health care services of the city of Campo Grande – MS with attending in the specialty of Rheumatology were invited to participate in the study through a standardized form of clinical and socio-demographic assessment. Physicians of any specialty could report a suspected case of systemic sclerosis, but necessarily the definitive diagnosis should be established by a rheumatologist, in order to warrant the standardization of diagnostic criteria and exclusion of other diseases resembling systemic sclerosis. At the end of the study, 15 rheumatologists reported that they attended patients with systemic sclerosis and sent the completed forms containing epidemiological data of patients. Results: The incidence rate of systemic sclerosis in Campo Grande for the year 2014 was 11.9 per million inhabitants and the prevalence rate was 105.6 per million inhabitants. Systemic sclerosis patients were mostly women, white, with a mean age of 50.58 years, showing the limited form of the disease with a mean duration of the disease of 8.19 years. Regarding laboratory tests, 94.4% were positive for antinuclear antibody, 41.6% for anti-centromere antibody and 19.1% for anti-Scl70; anti-RNA Polymerase III was performed in 37 patients, with 16.2% positive. Conclusions: The city of Campo Grande, the state capital of MS, presented a lower incidence/prevalence of systemic sclerosis in comparison with those numbers found in US studies and close to European studies’ data.

Resumo Introdução: A esclerose sistêmica (ES) é uma enfermidade autoimune, extremamente heterogênea na sua apresentação clínica e segue um curso variável e imprevisível. Embora algumas discrepâncias nas taxas de incidência e prevalência entre regiões possam refletir as diferenças metodológicas na definição e verificação dos casos, elas também podem refletir as verdadeiras diferenças locais. Objetivos: Conhecer a prevalência e incidência da ES na cidade de Campo Grande, capital do Estado de Mato Grosso do Sul (MS), Brasil, de janeiro a dezembro de 2014. Métodos: Todos os serviços de saúde de Campo Grande (MS) que tinham atendimentos na especialidade de reumatologia foram convidados a participar do estudo por meio de ficha padronizada de avaliação clínica e sociodemográfica. Médicos de qualquer especialidade poderiam reportar um caso suspeito de ES, mas obrigatoriamente o diagnóstico definitivo deveria ser feito por um reumatologista, para garantir a padronização dos critérios diagnósticos e excluir outras doenças que se assemelham à ES. No fim do estudo 15 reumatologistas relataram ter atendido pacientes com diagnóstico de ES e enviaram os formulários preenchidos com os dados epidemiológicos dos pacientes. Resultados: A taxa de incidência de ES em Campo Grande em 2014 foi de 11,9 por milhão/habitantes e a de prevalência foi de 105,6 por milhão/habitantes. Os pacientes com ES eram principalmente mulheres, da cor branca, média de 50,58 anos, forma limitada da doença e tempo de evolução médio da doença de 8,19 anos. Em relação aos exames laboratoriais, observou-se a positividade de 94,4% para o ANA, 41,6% para ACA e 19,1% para anti-Scl70, o anticorpo anti-POL3 foi feito em apenas 37 pacientes, com positividade de 16,2%. Conclusões: A capital do Estado de Mato Grosso do Sul, Campo Grande, apresentou dados de incidência e prevalência de ES inferiores aos encontrados em estudos americanos e próximos aos dados observados em estudos europeus.

What rheumatologists should know about orofacial manifestations of autoimmune rheumatic diseases / O que o reumatologista deve saber sobre as manifestações orofaciais das doenças reumáticas autoimunes

ABSTRACT Orofacial manifestations occur frequently in rheumatic diseases and usually represent early signs of disease or of its activity that are still neglected in clinical practice. Among the autoimmune rheumatic diseases with potential for oral manifestations, rheumatoid arthritis (RA), inflammatory myopathies (IM), systemic sclerosis (SSc), systemic lupus erythematosus (SLE), relapsing polychondritis (RP) and Sjögren's syndrome (SS) can be cited. Signs and symptoms such as oral hyposalivation, xerostomia, temporomandibular joint disorders, lesions of the oral mucosa, periodontal disease, dysphagia, and dysphonia may be the first expression of these rheumatic diseases. This article reviews the main orofacial manifestations of rheumatic diseases that may be of interest to the rheumatologist for diagnosis and monitoring of autoimmune rheumatic diseases.

RESUMO Manifestações orofaciais ocorrem com frequência nas doenças reumáticas e, comumente, representam sinais iniciais ou de atividade da doença que ainda são negligenciados na prática clínica. Entre as doenças reumáticas autoimunes com possíveis manifestações orais, incluem-se a artrite reumatoide (AR), miopatias inflamatórias (MI), esclerose sistêmica (ES), lúpus eritematoso sistêmico (LES), policondrite recidivante (PR) e síndrome de Sjögren (SS). Sinais e sintomas orofaciais como hipossalivação, xerostomia, disfunções temporomandibulares, lesões na mucosa bucal, doença periodontal, disfagia e disfonia podem ser a primeira expressão dessas doenças reumáticas. Esse artigo revisa as principais manifestações orofaciais das doenças reumáticas que podem ser de interesse do reumatologista, para diagnóstico e acompanhamento das doenças reumáticas autoimunes.

Human brucellosis mimicking axial spondyloarthritis: a challenge for rheumatologists when applying the 2009 ASAS criteria / 华中科技大学学报（医学）（英德文版）

Although the development of the 2009 SpA classification criteria by Assessment of SpondyloArthritis international Society (ASAS) represents an important step towards a better definition of the early disease stage particularly in axial spondyloarthritis (axSpA), the specificity of the criteria has been criticized these days. As the commonest zoonotic infection worldwide, human brucellosis can mimic a large number of diseases, including SpA. This study was performed to determine the frequency of rheumatologic manifestations in patients with brucellosis and the chance of misdiagnosing them as having axSpA in central China. The results showed that clinical manifestations of axSpA could be observed in brucellosis. Over half of patients had back pain, and one fifth of the patients with back pain were less than 45 years old at onset and had the symptom for more than 3 months. Two young males were falsely classified as suffering from axSpA according to the ASAS criteria, and one with MRI proved sacroiliitis was once given Etanercept for treatment. Therefore, differential diagnosis including human brucellosis should always be kept in mind when applying the ASAS criteria, even in traditionally non-endemic areas.

The specialist physician's approach to rheumatoid arthritis in South Africa

Rheumatoid arthritis (RA) is expected to increase in Africa and South Africa. Due to the low numbers of rheumatologists in South Africa, specialist physicians also have to care for patients with RA. Furthermore several new developments have taken place in recent years which improved the management and outcome of RA. Classification criteria were updated, assessment follow-up tools were refined and above all, several new biological disease-modifying anti-rheumatic drugs were developed. Therefore it is imperative for specialist physicians to update themselves with the newest developments in the management of RA. This article provides an overview of the newest developments in the management of RA in the South African context. This approach may well apply to countries with similar specialist to patient ratios and disease profiles.

Manifestaciones osteoarticulares por amiloidosis sistémica / Osteoarticular manifestations by systemic amyloidosis

La amiloidosis es un grupo de enfermedades cuyo común denominador es el depósito extracelular de fibrillas insolubles derivadas de proteínas en órganos y tejidos. De acuerdo a su etiología y al tipo de proteína depositada existen varias clases de amiloi-dosis. A pesar que la incidencia de amiloidosis sisté -mica secundaria (AA) ha disminuido notoriamente con el advenimiento de drogas modificadoras de la enfermedad (DMARD) y terapia biológica, continúa siendo el tipo de amiloidosis más frecuentemente observada por el reumatólogo. En este artículo revisamos la historia, clasificación, epidemiología, diagnóstico y tratamiento de la amiloidosis sistémica haciendo énfasis en las manifestaciones osteoar-ticulares que produce la enfermedad y en las distintas enfermedades reumatológicas que pueden originar una amiloidosis secundaria (AA). Así mismo publicamos un material fotográfico recopilado durante 20 años en diferentes centros de reumatología del país que es de gran ayuda para realizar el diagnóstico clínico de esta infrecuente patología.

Amyloidosis is a generic term that refers to the extracellular tissue deposition of fibrils composed of low molecular weight subunits of a variety of proteins. Amyloidosis classification depends on its etiology and subtype of protein involved. Systemic secondary amyloidosis (AA) is the most frequent subtype seen on rheumatology services because rheumatoid arthritis is currently the most frequent cause of AA, although its incidence has been declined because a better treatment of rheumatoid arthritis with disease-modifying anti-rheumatic drugs (DMARD). In this review we provide a general overview of the pathogenesis, clinical manifestations, diagnosis, and treatment of the systemic amyloidosis, emphasizing on the rheu-matic manifestations of these disorders. Besides, we present a photographic material obtained in the last 20 years in several rheumatologic centers in our country that it has a crucial role in the diagnosis and follow-up of this infrequent pathology.

Historia de las vasculitis primarias en Latinoamérica / History of primary vasculitis in Latinoamerican

En este artículo se hace una revisión extensa sobre las vasculitis primarias y se recopila la información latinoamericana que aparece referen-ciada en las más importantes bases de datos mundiales en inglés, español y portugués, desde el año 1945 hasta septiembre del año 2007. Igualmente se establecieron varios contactos con reumatólogos o médicos interesados en este tópico. Se realizaron búsquedas secundarias de los estudios que aparecieran citados en los artículos seleccionados y se revisaron manualmente abstracts de congresos.

In this paper an extensive review about primary vasculitis and Latino American information that appears referenced in the most important world wide data bases in English, Spanish and Portuguese from 1945 to september 2007, is compiled. Several contacts with rheumatologist or physician interested in this topic were made. Also secondary searches of the studies that appeared mentioned in selected articles were made and the abstracts of congresses were reviewed manually.

La ultrasonografía en reumatología: un antes y un después / Before and after sonography is applied in rheumatology

La ultrasonografía es una técnica diagnóstica y terapéutica de relativamente reciente introducción en reumatología, en vertiginoso desarrollo tecnológico y en pleno auge en cuanto a aplicación clínica e investigación. Su empleo ha sido posterior al de otras especialidades porque los medios técnicos necesarios para obtener imágenes de suficiente calidad del aparato locomotor comenzaron a desarrollarse a finales de los años 80, con la fabricación de las sondas lineales de alta frecuencia-alta resolución actualmente disponibles. Con la ecografía la deducción diagnóstica clásica se ha hecho más profunda porque esta técnica nos permite ver lo que está ocurriendo debajo de la piel, en los tendones, músculos y articulaciones, sin dañar al paciente. Por ello, es una herramienta idónea en la práctica diaria del reumatólogo ya que se convierte en una extensión de la exploración física en lugar de una exploración complementaria convencional más. La ecografía es una técnica válida y fiable para el estudio de las estructuras periarticulares e intraarticulares implicadas en las enfermedades reumatológicas. Es relativamente económica, inocua, rápida, repetible, dinámica y bien aceptada por el paciente. Se realiza en tiempo real en la misma consulta, permitiendo una correlación inmediata entre los datos clínicos y las imagenes del paciente. Finalmente, una aplicación esencial es la ecografía intervencionista, en la que podemos guiar las punciones diagnósticas y/o terapéuticas del aparato locomotor mediante la visualización del trayecto de las agujas de punción en la pantalla, con lo que conseguimos el alcance preciso y seguro de la lesión.

Within the last 20 years, the development of high frequency transducers, which have greatly improved musculoskeletal US imaging has led to a widespread use of ultrasonography as a diagnostic and therapeutic technique in rheumatology. Sonography has become a powerful diagnostic and research tool in clinical rheumatology that adds valuable information simultaneously to clinical evaluation. The incorporation of ultrasound to rheumatology has been a logical extension of its established practice in other specialities such as obstetrics, gynaecology and cardiology. High resolution musculoskeletal ultrasonography is a valid and reliable method for assess-ing periarticular and intraarticular anatomic structures involved in rheumatic disease. Ultrasonography has considerable advantages over other imaging modalities including non invasiveness, speed of performance, relative low cost, ability to scan multiple joints, repeatability and high patient acceptability. Musculoskeletal dynamic examina-tion in real time can be performed routinely, which shows the movement of tendons and muscles and aids the detection of abnormalities. In addition, ultrasound can be used for guidance of musculoskeletal injections and biopsies. Last but not least, rheumatologists can undertake inoffice MSUS, avoiding referral to radiologists and saving time and money.