Adriana Maria Kakehasi

The presence of Helicobacter Pylori in postmenopausal women is not a factor to the decrease of bone mineral density

BACKGROUND Osteoporosis affects approximately 30% of postmenopausal women. Gastrectomy, pernicious anemia, and more recently Helicobacter pylori infection, have all been implicated in the pathogenesis of osteoporosis. A reduced parietal cell mass is a common feature in these conditions. AIM To study a possible relationship between chronic gastritis, parietal cell density of the oxyntic mucosa and bone mineral density in postmenopausal women, as chronic gastritis, Helicobacter pylori infection and osteoporosis are frequently observed in the elderly. METHODS Fifty postmenopausal women (61.7 +/- 7 years) were submitted to gastroduodenal endoscopy and bone densitometry by dual energy X-ray absorptiometry. Glandular atrophy was evaluated objectively by the determination of parietal cell density. Helicobacter pylori infection was evaluated by histology, urease test and breath test with 13C. RESULTS Thirty-two patients (64%) presented chronic multifocal gastritis, and 20 of them (40%) showed signs of gastric mucosa atrophy. Lumbar spine osteoporosis was found in 18 patients (36%). The parietal cell density in patients with and without osteoporosis was 948 +/- 188 and 804 +/- 203 cells/mm(2), respectively. Ten osteoporotic patients (55%) and 24 non-osteoporotic patients (75%) were infected by Helicobacter pylori. CONCLUSION Postmenopausal women with osteoporosis presented a well-preserved parietal cell density in comparison with their counterparts without osteoporosis. Helicobacter pylori infection was not different between the two groups. We concluded that neither atrophic chronic gastritis nor Helicobacter pylori seem to be a reliable risk factor to osteoporosis in postmenopausal women.

Thyroid abnormalities in systemic lupus erythematosus: a study in 100 Brazilian patients

INTRODUCTION: the association of thyroid abnormalities with systemic lupus erythematosus (SLE) is not well established. OBJECTIVE: to study the prevalence of thyroid dysfunction in hundred lupus patients and evaluate a possible association between thyroid dysfunction and SLE disease activity. METHODS: a total of one hundred patients with SLE underwent assessment for clinical and laboratorial thyroid abnormalities. Clinical activity was assessed using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). RESULTS: seventeen patients (17%) had abnormal thyroid function by laboratory testing, which included ten patients (10%) with subclinical hypothyroidism, two patients (2%) with subclinical hyperthyroidism, four patients (4%) with primary hypothyroidism and one patient with serum thyroxine below the normal range. Regarding antithyroid antibodies, six patients were positive, as follows: four (4%) for antiperoxidase, one (1%) for antithyroglobulin and one (1%) for both antibodies. SLE disease activity was not significantly different between groups, regardless of the presence of thyroid dysfunction. CONCLUSION: these results show that thyroid abnormalities are frequently found in SLE patients. However, it does not appear to be an association between thyroid abnormalities and SLE clinical disease activity.

Diretrizes para o tratamento da síndrome do anticorpo antifosfolipídeo

The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial and venous thrombosis, gestational morbidity and presence of elevated and persistently positive serum titers of antiphospholipid antibodies. The treatment of APS is still controversial, because any therapeutic decision potentially faces the risk of an insufficient or excessive antithrombotic coverage associated with anticoagulation and its major adverse effects. This guideline was elaborated from nine relevant clinical questions related to the treatment of APS by the Committee of Vasculopathies of the Brazilian Society of Rheumatology. Thus, this study aimed at establishing a guideline that included the most relevant and controversial questions in APS treatment, based on the best scientific evidence available. The questions were structured by use of the PICO (patient, intervention or indicator, comparison and outcome) process, enabling the generation of search strategies for evidence in the major primary scientific databases (MEDLINE/PubMed, Embase, Lilacs, Scielo, Cochrane Library, Premedline via OVID). A manual search for evidence and theses was also conducted (BDTD and IBICT). The evidence retrieved was selected based on critical assessment by using discriminatory instruments (scores) according to the category of the therapeutic question (JADAD scale for randomized clinical trials and Newcastle-Ottawa scale for non-randomized studies). After defining the potential studies to support the recommendations, they were selected according to level of evidence and grade of recommendation, according to the Oxford classification.

Guidelines for the treatment of antiphospholipid syndrome

The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial and venous thrombosis, gestational morbidity and presence of elevated and persistently positive serum titers of antiphospholipid antibodies. The treatment of APS is still controversial, because any therapeutic decision potentially faces the risk of an insufficient or excessive antithrombotic coverage associated with anticoagulation and its major adverse effects. This guideline was elaborated from nine relevant clinical questions related to the treatment of APS by the Committee of Vasculopathies of the Brazilian Society of Rheumatology. Thus, this study aimed at establishing a guideline that included the most relevant and controversial questions in APS treatment, based on the best scientific evidence available. The questions were structured by use of the PICO (patient, intervention or indicator, comparison and outcome) process, enabling the generation of search strategies for evidence in the major primary scientific databases (MEDLINE/PubMed, Embase, Lilacs, Scielo, Cochrane Library, Premedline via OVID). A manual search for evidence and theses was also conducted (BDTD and IBICT). The evidence retrieved was selected based on critical assessment by using discriminatory instruments (scores) according to the category of the therapeutic question (JADAD scale for randomized clinical trials and Newcastle-Ottawa scale for non-randomized studies). After defining the potential studies to support the recommendations, they were selected according to level of evidence and grade of recommendation, according to the Oxford classification.

Fadiga óssea: causa de dor em joelhos na osteoartrite

Knee pain is the most frequent symptom in osteoarthritis, a condition that is the leading cause of chronic disability in the elderly and one of the main sources of morbidity attributable to osteoarthritis in general. The causes of knee pain in individuals with osteoarthritis cannot be easily understood, and the knowledge of such causes is critical for determining future specific interventions. Bone attrition represents remodelling of the subchondral bone envelope in osteoarthritis, leading to a consequential change in bone shape and/or bone loss. However, bone attrition is not a feature that can be easily read, since it is hardly detected in the absence of clear defects of cortical bone integrity and because of overlap of bone structures at radiography. Bone attrition is associated not only with knee pain, but also with stiffness and disability. If attrition occurs prior to advanced osteoarthritis, this would suggest that changes in subchondral bone occur concurrently with cartilage loss and that treatments targeting cartilage loss alone are unlikely to be effective. Association with edema-like bone marrow lesions may be observed and constitute predictive factors for subchondral bone attrition. The present study was aimed at reviewing the literature, demonstrating the relevance of bone attrition and explaining how to diagnose this entity on imaging studies.

Libman-Sacks Endocarditis and Oral Anticoagulation

The patient is a 34-year-old female with systemic lupus erythematosus and secondary antiphospholipid antibody syndrome, who evolved with convulsive crises, partially controlled with an anticonvulsant, and auscultation of a cardiac murmur, whose investigation showed the presence of a mitral valve vegetation. Once the diagnosis of Libman-Sacks endocarditis was established, therapy with warfarin sodium was initiated, and, after 6 months of oral anticoagulation, the patient had total control of the convulsive crises and the valvular vegetation disappeared on echocardiography. This study discusses the occurrence of Libman-Sacks endocarditis in systemic lupus erythematosus, its association with antiphospholipid antibody syndrome, and the anticoagulant therapy. A literature review is also provided.

Movimentos involuntários anormais como primeira manifestação do lupus eritematoso sistêmico: relato de caso

We describe a 36 year-old woman who developed chorea two months after starting the use of oral contraceptives. She also developed thrombocytopenia, oral ulcers, arthritis, positive antinuclear antibodies (ANA), anti-Sm and anti-DNA, filling criteria for systemic lupus erythematosus, as defined by the American College of Rheumatology. The tests for lupus anticoagulant and anticardiolipin (IgG and IgM) were negative. The patient was treated with prednisone, phenitoin, phenobarbital and clonazepam, obtaining clinical and labatorial improvement. We discuss the ocurrence of chorea and other movement disorders as first manifestation of systemic lupus erythematosus, its relationship with oral contraceptives and antiphospholipid antibodies.

Adalimumab in rheumatoid arthritis treatment: a systematic review and meta-analysis of randomized clinical trials

Since the discovery of the role of tumor necrosis factor in the physiopathological process of rheumatoid arthritis, five drugs that block this cytokine have been used as therapeutic options. To evaluate the efficacy and safety of adalimumab in the treatment of rheumatoid arthritis we performed a systematic review and meta-analysis of randomized controlled trials. A search of relevant studies in Medline (through PubMed) and LILACS in June 2011 was carried out. Study selection, data collection and analysis were performed in pairs and independently by two reviewers and by a third reviewer in cases of disagreement. The meta-analysis was performed using the software Review Manager® 5.1 using the random effects model. Eleven articles related to adalimumab were included and considered nine studies with 3461 patients. Ten studies showed low risk of bias regarding the blinding of participants and personnel and blinding of outcome assessment. Patients who received the combination treatment of adalimumab and methotrexate showed better efficacy results and lower radiographic progression when compared to placebo + methotrexate in 24-104 weeks. Patients who received adalimumab as monotherapy showed better efficacy outcomes when compared to placebo in 24 and 26 weeks. The results of the meta-analyses of adverse events were not statistically significant, except for reactions at the injection site, which favored the control group. Adalimumab efficacy was demonstrated in monotherapy and when associated to a DMARD, but the evidence for combined use is more robust.

Serum levels of vitamin B12 are not related to low bone mineral density in postmenopausal Brazilian women

INTRODUCTION: Osteoporosis and vitamin B12 deficiency are conditions with an increasing prevalence over time. It has been described an association between low serum vitamin B12, osteoporosis and increased risk of bone fractures, but the studies are heterogeneous and the results are controversial. OBJECTIVE: To investigate the association between plasma levels of vitamin B12 and bone mineral density in a group of asymptomatic women after menopause. METHODS: Asymptomatic postmenopausal women were consecutively invited to participate in this cross-sectional study. Bone mineral density (lumbar spine and femur) was measured by DXA Lunar Prodigy Vision, and blood levels of vitamin B12, calcium, phosphorus, bone alkaline phosphatase (BAF), and parathyroid hormone were determined. For the diagnostic of osteoporosis the World Health Organization criteria were considered. RESULTS: Seventy women were included, mean age 62.5 ± 7 years. Eighteen (25.7%) women had normal bone mineral density, 33 (47.1%) had osteopenia and 19 (27.1%) had osteoporosis. Six (8.6%) patients had wrist fracture; two (2.8%) reported a diagnosis of vertebral fracture and only one (1.4%) patient had suffered a hip fracture. The levels of vitamin B12 (mean ± SD, pg/mL) of women with normal bone mineral density, osteopenia and osteoporosis were 590.2 ± 364.3, 536.6 ± 452.3, and 590.2 ± 497.9, respectively (P = 0.881). Multiple regression analysis showed that body mass index and BAF were the main predictors of lumbar spine bone mineral density. CONCLUSION: The results indicate that vitamin B12 serum levels are not related to bone mineral density in this group of Brazilian postmenopausal women.

Skeletal abnormalities of tricho-rhino-phalangeal syndrome type I.

The tricho-rhino-phalangeal syndrome (TRPS) type I is a rare genetic disorder related to the TRPS1 gene mutation in chromosome 8, characterized by craniofacial abnormalities and disturbances in formation and maturation of bone matrix. The hallmarks are sparse and brittle hair, tendency to premature baldness, bulbous nose called pear-shaped, long and flat filter and low ear implantation. The most noticeable skeletal changes are clinodactyly, phalangeal epiphyses of the hands appearing as cone-shaped, short stature and hip joint malformations. We report a case of a teenager boy diagnosed with TRPS and referred for rheumatologic evaluation due to joint complaints.