Polyarticular lipoma arborescens--a clinical and aesthetical case.

Lipoma arborescens is a benign tumor, but it may be a reactive process to other disorders, and its clinical, analytical, radiological and ultrasound presentation may be redundant to any synovial tumor. Despite the characteristic feature on magnetic resonance imaging (MRI), the correct differential diagnosis in atypical presentation, and the need for timely removal of the lesion to prevent joint damage, forces, ultimately, to invasive procedures. The clinical case reported here, fourth described in English language publications on the polyarticular form, also presented other specificities related to one of the swellings, in the knee. Because of its atypical location in the popliteal fossa, recurrent episodes of joint effusion, personal history of knee trauma, pulmonary tuberculosis, and family history of rheumatoid arthritis required particular attention. This process was hampered by the refusal of knee (and ankle) surgery by the patient. He accepted surgical removal of the swellings of the wrists, for aesthetical reasons, with pathologic confirmation of the diagnosis, and clinical success in that location. MRI of the knee showed the typical image of lipoma arborescens, but also other changes that compromise the prognosis.

[Arthritis and clinical history]. / A artrite e a história clínica.

In front of a patient with arthritis, clinical good-sense tells that the most probable diagnosis are the most prevalent ones. Nevertheless, we have to exclude a multiplicity of other aetiologies, less frequent, but with highest implications in the therapeutic conduct. Infections by Brucella and by Borrelia are rare causes of chronic arthritis, yet are diagnosis to consider, even when the clinical manifestations aren't the most typical, as there still exist endemic areas in Portugal. Here we report two clinical cases about patients with arthritis for more than one year, subject to ineffective exams ant treatments. Only the clinical history could put on evidence clinical-epidemiological data, suggestive of Brucellosis and Lyme Disease, namely the professional contact with infected animals, and the history of probable erythema migrans, that pointed toward the correct diagnosis. So, with directed therapeutic, there was complete resolution of the inflammatory symptoms.

[Vitamin D measurement in Portuguese patients with fragility fractures]. / Níveis séricos de vitamina D em portugueses com fracturas de fragilidade.

OBJECTIVES: Osteoporosis is a «silent epidemic¼, resulting from a combination of many possible causal and risk factors, which prevalence depend on particular features of the population. The authors propose to characterize some of these elements, with special attention to vitamin D (vitD) levels, in a Portuguese population at risk, selected on the basis of a history of prior fragility fracture. METHODS: Participants were selected from the computerized list of discharges from all hospitalized patients in a Central Hospital in Oporto, between the dates 1/1/2002 and 31/12/2004, with the diagnosis of low-impact fracture of the wrist. They were invited to a reassessment of their risk of fracture, after 5 to 7 years from that event. For each one, a protocol was completed, focusing on clinical, epidemiological, laboratorial, radiological and densitometric parameters. RESULTS: In this population, as expected, there was a high rate of osteoporosis risk factors, which may explain the also high rate of subsequent osteoporotic fractures. Among others, early menopause, low intake of calcium and protein, levels of vitD generally inadequate and low frequency of osteopo-rosis treatment were noticed. DISCUSSION: The widespread insufficiency of vitD, described in other populations, mostly from the Northern countries, was also found here, supporting the suspicion that also in Portugal low vitD levels could be prevalent, despite the supposed regular sun exposure. These and other observations in this series, to be proven in directed studies, should, meanwhile, raise the levels of awareness of the community, but particularly health professionals and policymakers of public health, in a matter with a strong impact on individual and collective health in the country.

[Hospitalization of patients with systemic sclerosis: characteristics of a population]. / Hospitalização de doentes com Esclerose Sistémica: caracterização de uma população.

OBJECTIVES: The authors propose to characterize a population in the area of reference of the Hospital de São João (HSJ) in Oporto, with severe manifestations of Systemic Sclerosis (SS), and need of hospitalization in this institution. Given the lack of data referring to SS in inpatient set (and its inexistence in Portugal), this elements may obviate a parallelism with populations described in other countries, or even identify specificities of this population, that in the future, can be important to study measures directed to optimizing their care, in Portugal. METHODS: The cases were collected from a computerized database containing all discharge registers of the Rheumatology Department of HSJ from 1/1/2003 to 31/12/2008 (6 years), diagnosed of SS (ICD9-CM code of 710,1). All the 40 inpatient records, reporting to 25 patients, were submitted to medical review, and for each of them, fulfilled a clinical protocol, focusing on multiple epidemiological and clinical characteristics, relative to evolution, manifestations and therapies, reason and outcome of hospitalization, and co-morbidities. RESULTS: The characteristics found in this population approach, globally, to the ones described previously, in other countries. However, the prevalence and severity of the cutaneous lesions suggest a higher impact of the cutaneous attainment in this casuistic. It would be of all interest to develop studies that could properly evaluate this observation. DISCUSSION: It is essential to profoundly know the disease, and the individual and population particularities, so we can act adequately. This study may have put on evidence some problems that, in the future, will probably have major impact on personal life and public health care resources in Portugal. They reflect direct and indirect costs, explained by the high rate of recurrent and long hospitalizations, making use of more expensive diagnostic tests and treatments, and the risk of higher morbidity. Early intervention may be modifying of the natural course of the disease in the long term.

Compliance in gout patients.

INTRODUCTION: Despite its relative high prevalence,potential devastating clinical consequences and socio-economic impact, the existence of effective drugs to treat it, and the well recognised direct relation between acute flares and treatment interruptions and its resumption, gout is still often considered the chronic disease with the worst rate of adherence to therapy. The reason for this is unknown. We proposed to thoroughly evaluate a subgroup of patients, aiming at identifying the clinical features predictive of non-compliance, and 5 different ways to assess those. METHODS: We analysed a number of clinical, analytical and ultrasound data relating to 34 gout patients (according to the Wallace-ARA diagnostic criteria for gout 1977 and the EULAR recommendations for gout diagnosis 2006), which were followed in a specialized rheumatology consultation as part of an ongoing study for ultrasound validation in gout. To assess non-compliance, we compared the prevalence of each one of these clinical features with 5 outcomes (2 of which related to "non-compliance": self-report of non-adherence to therapy and missing consultation, and 3 other outcomes related to "non-response": gout flare(s), final serum uric acid (sUA) ≥ 6 mg/dL, and no sonographic improvement) registered during a 1 year of follow-up assessment. RESULTS: We have found an association between younger age, higher body mass index, previous treatment with urate lowering drugs, self-report of previous non-compliance, nephrolithiasis and hyperuricosuria and the "outcomes of non-compliance". These patients tended to be less often treated with NSAID and allopurinol, and more often treated with corticosteroid and benzbromarone during the 1 year follow-up. They have also presented higher rate of gout flares and final sUA. Evaluating the 3 "outcomes of non-response", we have noticed a tendency for association with long disease duration, self-report of previous non-compliance (frequently attributed to gout flare), higher initial sUA and kidney failure. These patients tended to be less often treated with NSAID, and more often treated with allopurinol. Gout flare correlated to self-report of non-compliance and no sonographic improvement. Sonographic non response also correlated to higher final sUA. CONCLUSIONS: This study shows an association between some clinical features and non-compliance, but above all, and unlike the majority of other studies, it has found a correlation between non-compliance with possible causes of worst response or lower rate of treatment, such as hyperuricosuria, nephrolithiasis, kidney failure, and contraindication for NSAID treatment. The data which is based on a comprehensive and detailed clinical assessment, might point out hidden elements, which might go beyond the visible non-compliance, contributing to the frequent lack of control of the disease.

[Osteoporotic fractures in pregnancy - conjunction of factors?]. / Osteoporose fracturária na gravidez - conjunção de factores?

Pregnancy-associated osteoporosis is rare and self--limiting. We report two clinical cases, with beginning of back pain during a 1st pregnancy. In the 1st case, the pain became severe after a fall, and she had other risk factors of fracture, like low calcium intake, and a treatment with thyroid hormones for weight loss. In the 2nd case, we did not find any. Both were diagnosed of osteoporosis by bone densitometry and radiology (multiple vertebral compression fractures). They had a favorable progression with life-style measures, calcium and vitamin D supplementation, and oral biphosphonate in the 2nd case. Nevertheless, both still suffer the impact.