Use of single photon emission computed tomography and magnetic resonance to evaluate central nervous system involvement in patients with juvenile systemic lupus erythematosus.

The objective of the present study was to identify the single photon emission computed tomography (SPECT) and magnetic resonance (MR) findings in juvenile systemic lupus erythematosus (JSLE) patients with CNS involvement and to try to correlate them with neurological clinical history data and neurological clinical examination. Nineteen patients with JSLE (16 girls and 3 boys, mean age at onset 9.2 years) were submitted to neurological examination, electroencephalography, cerebrospinal fluid analysis, SPECT and MR. All the evaluations were made separately within a period of 15 days. SPECT and MR findings were analyzed independently by two radiologists. Electroencephalography and cerebrospinal fluid analysis revealed no relevant alterations. Ten of 19 patients (53%) presented neurological abnormalities including present or past neurological clinical history (8/19, 42%), abnormal neurological clinical examination (5/19, 26%), and abnormal SPECT or MR (8/19, 42% and 3/19, 16%, respectively). The most common changes in SPECT were cerebral hypoperfusion and heterogeneous distribution of blood flow. The most common abnormalities in MR were leukomalacia and diffuse alterations of white matter. There was a correlation between SPECT and MR (P<0.05). We conclude that SPECT and MR are complementary and useful exams in the evaluation of neurological involvement of lupus.

Use of single photon emission computed tomography and magnetic resonance to evaluate central nervous system involvement in patients with juvenile systemic lupus erythematosus

The objective of the present study was to identify the single photon emission computed tomography (SPECT) and magnetic resonance (MR) findings in juvenile systemic lupus erythematosus (JSLE) patients with CNS involvement and to try to correlate them with neurological clinical history data and neurological clinical examination. Nineteen patients with JSLE (16 girls and 3 boys, mean age at onset 9.2 years) were submitted to neurological examination, electroencephalography, cerebrospinal fluid analysis, SPECT and MR. All the evaluations were made separately within a period of 15 days. SPECT and MR findings were analyzed independently by two radiologists. Electroencephalography and cerebrospinal fluid analysis revealed no relevant alterations. Ten of 19 patients (53 percent) presented neurological abnormalities including present or past neurological clinical history (8/19, 42 percent), abnormal neurological clinical examination (5/19, 26 percent), and abnormal SPECT or MR (8/19, 42 percent and 3/19, 16 percent, respectively). The most common changes in SPECT were cerebral hypoperfusion and heterogeneous distribution of blood flow. The most common abnormalities in MR were leukomalacia and diffuse alterations of white matter. There was a correlation between SPECT and MR (P<0.05). We conclude that SPECT and MR are complementary and useful exams in the evaluation of neurological involvement of lupus

The effect of rheumatoid arthritis on the quality of life of primary caregivers.

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

Pediatric Escola Paulista de Medicina Range of Motion Scale: a reduced joint count scale for general use in juvenile rheumatoid arthritis.

OBJECTIVE: Different instruments are available to measure functional status in juvenile rheumatoid arthritis (JRA); however, none is based on the evaluation of joint range of motion (ROM). We designed and evaluated a ROM scale to be used as a complementary instrument in daily practice with JRA as well as in trials. METHODS: The 10 joint movements of the Pediatric Escola Paulista de Medicina Range of Motion scale (Pediatric EPM-ROM) were derived from 25 initial movements. The selection was based on 2 criteria: (1) consensus among 3 pediatric rheumatologists, one physical therapist, and one occupational therapist; and (2) choice of movements that presented the highest scores in a pilot study involving patients with JRA. The score for each joint ranges from 0 (full movement) to 3 (severe limitation) and the cutoff degrees of motion are, in general, based on the lack of ability to perform some activities of daily living. The test-retest reliability was assessed by administering the scale twice by the same observer, 4 to 10 days apart, always in the morning. The interobserver reliability was evaluated on the same day by 2 independent observers. Cross sectional construct validity was also assessed by correlating the values of some clinical variables with the scores of the Pediatric EPM-ROM scale. RESULTS: The instrument was applied to 34 patients with JRA, 11 systemic, 11 polyarticular, and 12 pauciarticular. The mean EPM-ROM score was 0.57 (SD 0.54, min 0, max 2.05). The test-retest and interobserver correlation coefficients were 0.96 and 0.98, respectively. The Pearson correlation coefficients comparing scores of the Pediatric EPM-ROM scale and other variables were satisfactory: Childhood Health Assessment Questionnaire, r=0.55 (p<0.001); American College of Rheumatology global functional class, r=0.56 (p<0.001); and number of limited joints, r=0.65 (p<0.001). CONCLUSION: Our results provide evidence that the Pediatric EPM-ROM scale is a valid instrument to measure joint ROM in JRA.

The role of ambiental agents in Behçet's disease.

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

[Estimation of benefits and risks of the treatment of rheumatoid polyarthritis with glucocorticoids using the health-related quality of life measurements]. / Estimation des bénéfices et des risques du traitement de la polyarthrite rhumatoïde par les glucocorticoïdes à l'aide de mesures des préférences.

The purpose of this study was to use the utility approach to evaluate the risks and benefits of corticosteroid therapy in rheumatoid arthritis patients. The utility approach provides us with a quantitative measure of the value or preference a patient attaches to his overall health status defined on a scale from perfect health (1) to death (0). Benefits and toxicity are combined into a number reflecting the patients combined assessment of the benefits of treatment and the side-effects associated with it. Utility of 3 scenarios (rheumatoid arthritis patients treated respectively with no, 5 mg/day and 15 mg/day of prednisone) were determined through the time trade-off (TTO) and thermometer scale (TS) techniques. Twenty-five rheumatoid arthritis patients selected at random among subjects attending an outpatient clinic and 25 rheumatologists were interviewed using visual aids. Treatment with 15 mg/d prednisone was assigned the highest utilities by both patients and physicians. Coefficients of correlation between thermometer scale and time trade-off utilities were 0.675 (p < 0.01) for physician-assigned utilities and 0.518 (p < 0.05) for patient-assigned utilities. Medical decisions concerning rheumatoid arthritis patients should take into account the preferences of patients and physicians.

Critical appraisal of the pattern of antinuclear antibodies (ANA) testing requested over a six month period at the "Escola Paulista de Medicina" (EPM), São Paulo.

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

Reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid arthritis.

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