Ultrasonographic and resistance index evaluation of nails in psoriatic arthritis, psoriasis, and control groups: a cross-sectional study

Abstract Background: Nail psoriasis occurs frequently in patients with psoriatic disease, it can lead to functional impairment, pain, discomfort, decreased quality of life and can also be a predictor for the development of arthritis. Early recognition of this condition can provide early and effective treatment and prevent structural impairment. This study aims to identify nail ultrasonographic characteristics in three groups: psoriasis (PsO), psoriatic arthritis (PsA) and controls patients, to determine if the ultrasonography (US) can identify early signs of nail psoriatic impairment or local inflammation. We conducted nail US to determine nail matrix resistance index (NMRI), nail bed resistance index (NBRI), and power Doppler (PD) and grayscale (GS) parameters in these 3 groups. Methods: Single-center, cross-sectional study. GS, PD, and spectral doppler images of bilateral 2nd and 3rd fingernails were acquired from 35 PsO, 31 PsA, and 35 controls patients. An US equipment with an 18 MHz linear transducer for GS and 8.0 MHz for PD was used. PD, NMRI, NBRI, nail plate thickness (NPT), nail bed thickness (NBT), nail matrix thickness (NMT), and morphostructural characteristics of the trilaminar structure (TS) were evaluated in saved images, blind. Results: Mean NMRI and NBRI did not differ between groups. Linear regression analysis detected no relationships between PsO or PsA and NMRI or NBRI. Nail PD grade did not differ between groups. Type I and IV TS changes were more frequent in PsO; types II and III changes were more frequent in PsA (p < 0.001). NPT was greater in PsA and PsO groups than controls: PsA 0.73 ± 0.14 mm, PsO 0.72 ± 0.15 mm, Controls 0.67 ± 0.10mm (p = 0.001). Conclusion: Echographic TS characteristics of the nail plate and NPT evaluated by GS are useful and can distinguish PsO and PsA nails from controls. NMRI, NBRI, and US nail microcirculation parameters could not distinguish psoriatic nails. Trial registration: 72762317.4.0000.5327 (Certificate of Presentation of Ethical Appreciation - CAAE -Plataforma Brasil) Avaiable in https://plataformabrasil.saude.gov.br/login.jsf

Dualities of the vitamin D in systemic sclerosis: a systematic literature review

Abstract Background: Systemic sclerosis (SSc) is a chronic disease characterized by autoimmunity, vasculopathy, and visceral and cutaneous fibrosis. Vitamin D has several functions in the immunological system, and different studies have suggested a potential role in triggering autoimmune diseases. Patients with SSc may present with low serum levels of vitamin D, but the association between hypovitaminosis D and disease onset or any clinical manifestation is still obscure. Our goal was to verify the causal relationship between hypovitaminosis D and SSc onset or any particular clinical manifestation in the literature. Methods: A systematic literature review was performed through February 24th, 2021 on Pubmed, Lilacs/BIREME, and Cochrane databases. The eligible studies were read in full text, and, in the absence of exclusion criteria, were included in this review after consensus between two reviewers. Results: Forty articles met the eligibility criteria and the main results of each study are described. In most studies, SSc patients showed a higher prevalence of vitamin D deficiency and insufficiency compared to controls. Additionally, in some reports serum levels of vitamin D were inversely correlated with the severity of SSc. Oral supplementation did not seem to affect serum levels of vitamin D. Four of the included studies were with experimental models. Conclusion: In conclusion, vitamin D deficiency seems to have a role in susceptibility to SSc, as well as in the clinical manifestations of the disease.

Flow cytometry evaluation of CD14/CD16 monocyte subpopulations in systemic sclerosis patients: a cross sectional controlled study

Abstract Background: Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by vasculopathy and fibrosis, which can be subclassified into diffuse cutaneous (dSSc) and limited cutaneous (lSSc) subtypes. Previous studies suggest that an increase in monocytes can be a hallmark of various inflammatory diseases, including SSc. Our aim was to evaluate circulating blood monocyte subpopulations (classical, intermediate and non-classical) of SSc patients and their possible association with disease manifestations. Methods: Fifty consecutive patients fulfilling the 2013 ACR/EULAR classification criteria for SSc were included in a cross-sectional study. Monocyte subpopulations were identified based on their expression of CD64, CD14 and CD16, evaluated by flow cytometry, and were correlated with the clinical characteristics of the patients; furthermore, the expression of HLA-DR, CD163, CD169 and CD206 in the monocytes was studied. Thirty-eight age- and sex-matched healthy individuals were recruited as a control group. Results: SSc patients had an increased number of circulating peripheral blood monocytes with an activated phenotypic profile compared to healthy subjects. Absolute counts of CD16+ (intermediary and non-classical) monocyte subpopulations were higher in SSc patients. There was no association between monocyte subpopulations and the clinical manifestations evaluated. Conclusion: We identified higher counts of all monocyte subpopulations in SSc patients compared to the control group. There was no association between monocyte subpopulations and major fibrotic manifestations. CD169 was shown to be more representative in dSSc, being a promising marker for differentiating disease subtypes.

Rheumatoid arthritis seems to have DMARD treatment decision influenced by fibromyalgia / As decisões de tratamento com DMARD na artrite reumatoide parecem ser influenciadas pela fibromialgia

Abstract Objective: To compare DMARD use in patients with and without FM over time, including overtreatment and undertreatment rates in both groups. Methods: A prospective cohort study with patients attending an RA outpatient clinic was conducted. Participants were consecutively recruited between March 2006 and June 2007 and were followed through December 2013. Data on DMARD use (prevalences, doses and escalation rates), DAS28, HAQ and radiographic progression were compared among RA patients with FM and without FM. Mistreatment clinical scenarios were allegedly identified and compared between groups. Results: 256 RA patients (32 with FM) were followed for 6.2 ± 2.0 (mean ± SD) years comprising 2986 visits. At baseline, RA duration was 11.1 ± 7.4 years. DAS28 and HAQ were greater in RA with FM group, and were closer to RA without FM group towards the end. RA patients with FM used higher doses of tricyclic antidepressants, leflunomide and prednisone, and lower doses of methotrexate. When compared to RA patients without FM, participants with RA and FM used more often tricyclic antidepressants, leflunomide, prednisone, continuous analgesics and less often methotrexate. Groups presented similar 7-year biologic-free survival, and radiographic progression-free survival in Cox regression. RA patients with FM had greater proportions of visits in mistreatment scenarios when compared to RA patients without FM (28.4 vs. 19.8%, p < 0.001). Conclusions: RA patients with FM used more leflunomide and prednisone, and RA mistreatment was more frequent in FM patients. Certainly, RA patients with FM will benefit from a personalized T2T strategy, including ultrasound (when suitable) and proper FM treatment.

Resumo Objetivo: Comparar o uso de fármacos antirreumáticos modificadores da doença (DMARD) em pacientes com e sem fibromialgia (FM) ao longo do tempo, incluindo as taxas de tratamento excessivo e subtratamento em ambos os grupos. Métodos: Estudo de coorte prospectiva com pacientes atendidos em um ambulatório de artrite reumatoide (AR). Os participantes foram recrutados consecutivamente entre março de 2006 e junho de 2007 e foram seguidos até dezembro de 2013. Compararam-se os dados de uso de DMARD (prevalências, doses e taxas de escalonamento), 28-Joint Disease Activity Score (DAS28), Health Assessment Questionnaire (HAQ) e progressão radiográfica entre pacientes com e sem FM. Os cenários clínicos de tratamento supostamente incorreto foram identificados e comparados entre os grupos. Resultados: Seguiram-se 256 pacientes com AR (32 com FM) por 6,2 ± 2,0 (média ± DP) anos, período que abrangeu 2.986 consultas. No início do estudo, a duração da AR era de 11,1 ± 7,4 anos. O DAS28 e o HAQ foram maiores no grupo AR com FM e estavam mais próximos do grupo AR sem FM no fim do estudo. Os pacientes com AR com FM usaram doses mais altas de antidepressivos tricíclicos, leflunomida e prednisona e doses mais baixas de metotrexato. Quando comparados com os pacientes com AR sem FM, os participantes com AR e FM usaram mais frequentemente antidepressivos tricíclicos, leflunomida, prednisona e analgésicos contínuos e menos frequentemente metotrexato. Os grupos apresentaram sobrevida em sete anos sem agentes biológicos e livres de progressão radiográfica semelhantes na regressão Cox. Os pacientes com AR com FM apresentaram uma maior proporção de consultas em cenários de tratamento supostamente incorreto quando comparados com os pacientes com AR sem FM (28,4 vs. 19,8%, p < 0,001). Conclusões: Os pacientes com AR e FM usaram mais leflunomida e prednisona e o tratamento supostamente incorreto na AR foi mais frequente em pacientes com FM. Os pacientes com AR com FM certamente se beneficiarão de uma estratégia personalizada de tratamento por metas (T2 T), incluindo ultrassonografia (quando apropriado) e controle da FM.

Identifying frailty syndrome with tug test in home-dwelling elderly / Identificação da síndrome da fragilidade com o teste TUG em idosos residentes na comunidade

Introduction: Frailty is an important geriatric syndrome linked to increased mortality, morbidity and the risk of falls Detection of pre-frail and early frail individuals is essential to minimize adverse health outcomes, enabling effective interdisciplinary interventions. Objective: To identify frailty syndrome with Timed Up and Go (TUG) test in home-dwelling elderly. Methods: A home-based cross-sectional study was carried out with 322 elderly people living in a Southern city of Brazil. The Fried frailty criteria was used in order to assess the levels of frailty; the TUG score was investigated as a possible predictor of frailty. The diagnostic ability of different cut-off points for the TUG test was evaluated using the ROC curve. Results: ROC curve analysis for the TUG test, a value of eight seconds was identified as the good cut-off point for the screening of the frailty syndrome. The AUROC was 0.775, with a sensitivity of 85.0%, specificity of 59.5% and negative predictive value of 78.6%. Conclusions: Considering the limitations of a single test to accomplish the overall complexity of frailty syndrome, in the present study, TUG test was a good screening tool in home-dwelling elderly.

Introdução: A fragilidade é uma importante síndrome geriátrica associada ao aumento da mortalidade, morbidade e risco de quedas. A detecção de indivíduos pré-frágeis e frágeis precoces é essencial para minimizar os efeitos adversos à saúde, possibilitando intervenções interdisciplinares eficazes. Objetivo: Identificar a síndrome de fragilidade com o teste Timed Up and Go (TUG) em idosos domiciliares. Métodos: Estudo transversal de base domiciliar, com 322 idosos residentes em uma cidade do Sul do Brasil. O critério de fragilidade de Fried foi utilizado para avaliar os níveis de fragilidade; O teste TUG foi investigado como um possível preditor de fragilidade. A capacidade diagnóstica de diferentes pontos de corte para o teste TUG foi avaliada utilizando a curva ROC. Resultados: A análise da curva ROC para o teste TUG, identificou-se um valor de oito segundos como o bom ponto de corte para a triagem da síndrome de fragilidade. O AUROC foi de 0,775, com sensibilidade de 85,0%, especificidade de 59,5% e valor preditivo negativo de 78,6%. Conclusões: Considerando as limitações de um único teste para realizar a complexidade geral da síndrome de fragilidade, no presente estudo, o teste TUG foi uma boa ferramenta de rastreamento em idosos domiciliares.

Hormônio anti-Mülleriano como preditor de reserva ovariana em pacientes lúpicas: uma revisão / Anti-Müllerian hormone levels as a predictor of ovarian reserve in systemic lupus erythematosus patients: a review

RESUMOO hormônio anti-Mülleriano (HAM) é secretado a partir das células da granulosa dos folículos ovarianos em crescimento e parece ser o melhor marcador endócrino capaz de estimar a reserva ovariana. O lúpus eritematoso sistêmico (LES) é uma doença autoimune que acomete predominantemente mulheres em idade reprodutiva e pode afetar negativamente sua fertilidade pela atividade da doença, bem como pelos tratamentos usados. Conhecer o real impacto do LES e de seu tratamento na fertilidade vem sendo o objetivo de estudos recentes, os quais têm usado o HAM para esse fim.

ABSTRACTThe anti-Müllerian hormone (AMH) is secreted from granulosa cells of growing ovarian follicles and appears to be the best endocrine marker capable of estimating ovarian reserve. Systemic lupus erythematosus (SLE) is an autoimmune disease that predominantly affects women of reproductive age and may negatively affect their fertility due to disease activity and the treatments used. Recently, several studies assessed AMH levels to understand the real impact of SLE and its treatment on fertility.

Fibromialgia: princípios práticos que auxiliam na indicação e no ajuste do tratamento medicamentoso / Fibromyalgia: practical principles that help in the indication and adjustment of drug treatment

A fibromialgia (FM) é uma síndrome de dor difusa crônica acompanhada de sintomas somáticos, tais como fadiga, transtornos do humor, do sono e da cognição. Em uma abordagem prática do paciente com FM, além das medidas não farmacológicas, cada sintoma pode ser tratado com medicamento específico. O objetivo deste artigo é prover revisão atualizada da literatura sobre os principais medicamentos atualmente disponíveis no Brasil para o tratamento da FM em adultos. O sucesso terapêutico da FM depende, essencialmente, do uso racional de medicamentos voltados para os sintomas refratários às medidas não farmacológicas.

Fibromyalgia (FM) is the chronic widespread pain syndrome associated with fatigue, mood, sleep and cognitive disorders. Besides non-pharmacological approach, each symptom should be treated with a specific drug. The goal of this study is to provide up-to-date literature review on main aspects of adult FM drugs available for use in Brazil. Treatment success in FM depends essentially on using drugs based on symptoms that are not responsive to non-pharmacological approach.

Aspectos atuais do tratamento medicamentoso da fibromialgia / Current aspects of drug treatment of fibromyalgia

Fibromialgia (FM) é a síndrome de dor difusa crônica acompanhada de sintomas somáticos, tais como fadiga, transtornos do humor, do sono e da cognição. Em uma abordagem prática do paciente com FM, além das medidas não farmacológicas, cada sintoma pode ser tratado com medicamento específico. Este artigo provê revisão atualizada da literatura sobre os principais medicamentos atualmente disponíveis no Brasil para o tratamento da FM em adultos

Fibromyalgia (FM) is the chronic widespread pain syndrome associated with fatigue, mood, sleep and cognitive disorders. Besides non-pharmacological approach, each symptom should be treated with a specific drug. The goal of this study is to provide up-to-date literature review on main aspects of adult FM drugs available for use in Brazil

Polymerase chain reaction as a useful and simple tool for rapid diagnosis of tuberculous meningitis in a Brazilian tertiary care hospital

Meningitis is a severe and potentially fatal form of tuberculosis. The diagnostic workup involves detection of acid-fast bacilli (AFB) in the cerebrospinal fluid (CSF) by microscopy or culture, however, the difficulty in detecting the organism poses a challenge to diagnosis. The use of the polymerase chain reaction (PCR) in the diagnostic approach to Mycobacterium tuberculosis (MTB) meningitis has been reported as a fast and accurate method, with several commercial kits available. As an alternative, some institutions have been developing inexpensive in house assays. In our institution, we use an in house PCR for tuberculosis. We analyzed the performance of our PCR for the diagnosis of MTB meningitis in 148 consecutive patients, using MTB culture as gold standard. The sensitivity and specificity of CSF PCR for the diagnosis of MTB meningitis was 50 percent and 98.6 percent respectively with a concordance with CSF mycobacterial culture of 96 percent (Kappa=0.52). In contrast to CSF cultures for MTB, our PCR test is a fast, simple and inexpensive tool to diagnose tuberculous meningitis with a performance similar to that obtained with the available commercial kits.

Esclerose sistêmica e níveis séricos elevados de organoclorado: uma associação possível? / Systemic sclerosis and elevated organochlorine blood levels: a possible association?

A patogênese da esclerose sistêmica (ES) é complexa e pouco conhecida. Há a participação de ativação imune, dano vascular e excessiva produção de matriz extracelular com deposição de colágeno estruturalmente normal. Fatores genéticos e ambientais contribuem para a expressão da doença nos pacientes. Dentre os fatores ambientais, diversos agentes químicos já foram associados à doença. Descrevemos o caso de uma adolescente de 16 anos, com história prévia de hepatite criptogênica e câncer de lábio, que desenvolveu quadro atípico e rapidamente progressivo de esclerose sistêmica. Inicialmente o quadro era compatível com esclerodermia em placas, porém rapidamente evoluiu para uma forma sistêmica com grave acometimento cardiopulmonar e óbito. Durante a investigação de possíveis fatores etiológicos que pudessem estar relacionados, foram encontrados níveis séricos extremamente elevados de oxiclordano, um agrotóxico organoclorado. Uma possível correlação entre a intoxicação por esse agente químico e o surgimento de ES foi aventada.

The pathogenesis of systemic sclerosis (SS) is complex and not completely understood. Autoimmune mechanisms, vascular damage, and excessive extracelular matrix with collagen deposition play a significant role. Genetic and environmental factors also are decisive to the disease expression. Among environmental factors many chemical agents have been associated with the development of SS. A 16-year-old white woman, with previous history of cryptogenic hepatitis and cancer of the lips, developed an atypical and rapidly progressive form of SS. Initial sclerodermatous plaques progressed to a systemic form with severe cardiopulmonary involvement and death. Diagnostic workup revealed extremely high blood levels of oxychlordane. A possible association of organochlorine intoxication and SS is proposed.

Apresentação grave de Doença de Still do adulto / Severe Still disease in adults

Doença de Still do Adulto (DAS), uma variante da artrite reumatóide juvenil, é uma síndrome caracterizada por artralgia, febre elevada, rash cutâneo, linfadenomegalia e hepatoesplenomegalia. O diagnóstico é de exclusão baseado em critérios estudados. O diagnóstico diferencial inclui infecções, malignidades e doenças imunológicas. O curso da doença varia entre formas leves e bem agressivas, havendo relatos de alguns casos de DSA evoluindo com choque. Paciente branca, feminina, quarenta e nove anos procura o hospital com queixa de febre, náusea e mialgia há três semanas com indisposição, artrite simétrica de mãos e febre com calafrios. Identificada esplenomegalia no exame físico e linfonodomegalia cervical posterior esquerda. Em três dias, apresentou hipotensão grave, insuficiência renal aguda (IRA), coagulação intravascular disseminada (CIVD) e acidose metabólica, preenchendo critérios para sepse grave e disfunção de múltiplos órgãos e sistemas (DMOS), sendo tratada com volume, drogas vasoativas, glicocorticóide em altas doses e proteína C ativada (drotrecogina). Foram iniciados cefepime e vancomicina empiricamente. Em uma semana, após melhora inicial, a paciente desenvolveu nova piora clínica. Prostração, febre, tosse seca e eritema, desta vez associados a petéquias em membros inferiores e leucopenia (1590 leucócitos, sendo 650 neutrófilos) surgiram e, como já havia dez dias de cefepime e vancomicina, foi iniciado novo esquema empírico para sepse hospitalar de origem desconhecida com meropenem e fluconazol. Glicocorticóide foi reinstituído como parte da abordagem de choque séptico e foi repetida a ecografia abdominal que não mostrou alterações evolutivas. Com base em vasto rastreamento infeccioso negativo, decidiu-se pela terapia imunossupressora com doses elevadas de glicocorticóide, sem suspensão dos antibióticos, sendo seu desfecho favorável. Apenas alguns casos de choque distributivo foram descritos no contexto de DSA e este seria o primeiro relato de um...