Eduardo de Souza Meirelles

Body composition, visceral fat distribution and fat oxidation in postmenopausal women using oral or transdermal oestrogen.

OBJECTIVES The aim of this study was to observe hysterectomized postmenopausal women (without progestogen, which could interfere in the results), using oral-conjugated oestrogen 0.625 mg daily (n=13) or 17beta-estradiol transdermal patches delivering 50 microg daily (n=10) during 12 months, and to evaluate the treatment effects on body composition, visceral fat distribution, energy expenditure and substrate oxidation. METHODS We studied 23 postmenopausal women using oral-conjugated oestrogen (Premarin) 0.625 mg daily (n=13) or transdermal oestrogen patches (Systen TTS) 50 microg daily (n=10). Body composition was measured by DEXA, visceral adipose tissue areas were measured by abdominal computed tomography, and energy expenditure, fat oxidation and carbohydrate oxidation were measured by indirect calorimetry (Deltatrac Metabolic Monitor). RESULTS There were: (1) a decrease in IGF-I and an increase in GH levels in the oral group and no change in the transdermal group; (2) a increase in lean body mass in the transdermal group and a decrease in the oral group; (3) a increase in total body fat mass in the oral group and no change in the transdermal group; (4) an increases in total bone mass and in total bone mineral density in the transdermal group and no change in the oral group; (5) an increase in lipid oxidation in the transdermal group and a decrease in the oral group, and (6) no significantly change about weight, visceral adipose tissue areas and energy expenditure in both groups. CONCLUSIONS The administration route of oestrogen replacement therapy in postmenopausal women confers distinct and divergent effects on body composition and substrate oxidation during 12-months treatment.

Influence of disease activity and chronicity on ankylosing spondylitis bone mass loss.

Abstract: We investigated 30 consecutive Brazilian patients with definite ankylosing spondylitis (AS) fulfilling the New York and the European spondyloarthropathy study group classification criteria. The mean age at study was 37 years old and the mean disease duration was 17 years. Bone densitometry employed the dual-energy X-ray absorptiometry (DEXA) technique, using a Hologic QDR-1000/W densitometer. Axial bone mineral density (BMD) was measured in the lumbar spine (L1–L4) and appendicular BMD was measured in the total proximal femur and sub-regions (neck, greater trochanter, intertrochanter and Ward’s triangle). Based on World Health Organisation criteria, the lumbar spine showed osteopenia or osteoporosis in 50% of the patients, while 86% had osteopenia or osteoporosis in the total proximal femur. When compared with the normal population, the patients showed a significant BMD decrease in the lumbar spine and total proximal femur with sub-regions, except for the femoral neck. A comparison of BMD between patients with active and inactive disease did not reveal a significant effect of clinical disease activity on the lumbar spine and total proximal femur with sub-regions, except for Ward’s triangle. Concerning disease chronicity, there were significant positive correlations between disease duration and lumbar spine, total proximal femur, greater trochanter and intertrochanteric regional BMD. This false increase in lumbar spine BMD found mostly in patients with long standing AS was due to the presence of paravertebral calcification and ossification. We conclude that the bone mass loss in AS is better evaluated in the proximal femur, because of the greater sensitivity of bone densitometry in this region, which is almost free of artefacts.

Consenso Brasileiro de Espondiloartropatias: espondilite anquilosante e artrite psoriásica diagnóstico e tratamento - primeira revisão

1. Assistente-doutor da Disciplina de Reumatologia do Departamento de Clinica Medica da Faculdade de Ciencias Medicas da Universidade Estadual de Campinas (FCM-UNICAMP). Presidente da Comissao de Espondiloartropatias da Sociedade Brasileira de Reumatologia (SBR). 2. Professor Assistente da Disciplina de Reumatologia da Universidade Federal do Parana (UFPR). Mestre em Medicina Interna. 3. Professor Assistente da Disciplina de Reumatologia da Pontificia Universidade Catolica de Campinas (PUCCAMP). 4. Professor Adjunto, Doutor em Oftalmologia da Universidade Federal de Minas Gerais (UFMG). 5. Professora Adjunta da Faculdade de Ciencias Medicas da Universidade Estadual do Rio de Janeiro (UERJ) e Professora do Programa de Pos-Graduacao em Medicina da Universidade Federal do Rio de Janeiro (UFRJ). 6. Professor Adjunto, Doutor de Reumatologia do Departamento do Aparelho Locomotor da Universidade Federal de Minas Gerais (UFMG). 7. Professor Doutor-Assistente e Coordenador da Unidade de Espondiloartropatias da Disciplina de Reumatologia da Faculdade de Medicina da Universidade de Sao Paulo (FMUSP). 8. Professora Associada e Responsavel pelo Setor de Reumatologia Pediatrica da Universidade Federal de Sao Paulo (UNIFESP). 9. Professor Regente da Disciplina de Reumatologia da Faculdade de Medicina da Pontificia Universidade Catolica do Rio Grande do Sul (PUC-RS). 10. Professor Titular de Reumatologia da Faculdade de Medicina Souza Marques, Rio de Janeiro – RJ. 11. Professora da Disciplina de Coloproctologia da Fundacao Faculdade Federal de Ciencias Medicas de Porto Alegre (FFFCMPA). 12. Assistente-Doutor e Chefe do Grupo de Reumatologia do Instituto de Ortopedia e Traumatologia da FMUSP. 13. Chefe do Servico de Reumatologia e Coordenador da Residencia Medica do Hospital Geral de Fortaleza. 14. Chefe do Departamento de Medicina Interna do Hospital Geral de Goiânia. Doutor em Reumatologia pela FMUSPUniversidade Estadual de Campinas Faculdade de Ciencias Medicas Departamento de Clinica Medica

Gender characterization in a large series of Brazilian patients with spondyloarthritis

An increasing number of women have been diagnosed with spondyloarthritis (SpA) in recent decades. While a few studies have analyzed gender as a prognostic factor of the disease, no studies have addressed this matter with a large number of patients in South America, which is a peculiar region due to its genetic heterogeneity. The aim of the present study was to analyze the influence of gender on disease patterns in a large cohort of Brazilian patients with SpA. A prospective study was carried out involving 1,505 patients [1,090 males (72.4%) and 415 females (27.6%)] classified as SpA according to the European Spondyloarthropaties Study Group criteria who attended at 29 reference centers for rheumatology in Brazil. Clinical and demographic variables were recorded and the following disease indices were administered: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Radiologic Index (BASRI), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), and Ankylosing Spondylitis Quality of Life (ASQoL). Ankylosing spondylitis (AS) was the most frequent disease in the group (65.4%), followed by psoriatic arthritis (18.4%), undifferentiated SpA (6.7%), reactive arthritis (3.3%), arthritis associated to inflammatory bowel disease (3.2%), and juvenile SpA (2.9%). The male-to-female ratio was 2.6:1 for the whole group and 3.6:1 for AS. The females were older (p < 0.001) and reported shorter disease duration (p = 0.002) than the male patients. The female gender was positively associated to peripheral SpA (p < 0.001), upper limb arthritis (p < 0.001), dactylitis (p = 0.011), psoriasis (p < 0.001), nail involvement (p < 0.001), and family history of SpA (p = 0.045) and negatively associated to pure axial involvement (p < 0.001), lumbar inflammatory pain (p = 0.042), radiographic sacroiliitis (p < 0.001), and positive HLA-B27 (p = 0.001). The number of painful (p < 0.001) and swollen (p = 0.006) joints was significantly higher in the female gender, who also achieved higher BASDAI (p < 0.001), BASFI (p = 0.073, trend), MASES (p = 0.019), ASQoL (p = 0.014), and patient’s global assessment (p = 0.003) scores, whereas the use of nonsteroidal anti-inflammatory drugs (p < 0.001) and biological agents (p = 0.003) was less frequent in the female gender. Moreover, BASRI values were significantly lower in females (p < 0.001). The female gender comprised one third of SpA patients in this large cohort and exhibited more significant peripheral involvement and less functional disability, despite higher values in disease indices.

Effect of enthesitis on 1505 Brazilian patients with spondyloarthritis.

Objective. To analyze the clinical effect of enthesitis in a large Brazilian cohort of patients with spondyloarthritis (SpA). Methods. A common protocol of investigation was prospectively applied to 1505 patients with SpA in 29 centers in Brazil. Clinical and demographic variables and disease indexes were investigated. The Maastricht Ankylosing Spondylitis Enthesitis Score was used to investigate the enthesitis component. Ankylosing spondylitis was the most frequent disease in the group (65.4%). Others were psoriatic arthritis (18.4%), undifferentiated SpA (6.7%), reactive arthritis (3.3%), and enteropathic arthritis (3.2%). Results. At least 1 affected enthesis was observed in 54% of the patients with SpA, with a mean of 2.12 ± 2.98 entheses affected. According to the clinical presentation, enthesitis was significantly more frequent in patients with axial + peripheral joint involvement compared to isolated axial or peripheral involvement (p < 0.001). There was a statistical association between the presence of enthesites and axial symptoms (buttock pain, cervical pain, and hip pain), and peripheral symptoms (lower limb arthritis, number of painful and swollen joints; p < 0.05). Patients with enthesitis also presented higher mean scores of Bath Ankylosing Spondylitis Functional Index (BASFI; p < 0.001), Bath Ankylosing Spondylitis Disease Activity Index (p < 0.001), and Ankylosing Spondylitis Quality of Life (ASQoL; p < 0.001). Multivariate logistic regression showed that BASFI (p < 0.0001; OR 74.839), ASQoL (p = 0.0001; OR 14.645), and Achilles tendonitis (p = 0.0059; OR 7.593) were associated with work incapacity. Conclusion. The clinical presence of enthesitis in this large cohort of patients with SpA was frequent and was associated with a significant increase in disease activity and decline in functional capacity and quality of life.

Recomendações sobre diagnóstico e tratamento da espondilite anquilosante

Descricao do metodo de elaboracao das evidencias Os integrantes da Comissao de Espondiloartrites da Sociedade Brasileira de Reumatologia (bienio 2010-2012) participaram do Curso de Elaboracao de Evidencias da Associacao Medica Brasileira, em Sao Paulo, durante o primeiro semestre de 2011. As questoes foram concluidas em reuniao presencial da Comissao de Espondiloartrites no dia 15 de outubro de 2011, durante a XVIII Jornada Cone Sul de Reumatologia, em Florianopolis (SC, Brasil), e foram posteriormente aprovadas por todos os coordenadores do Registro Brasileiro de Espondiloartrites. As 15 questoes clinicas consideradas relevantesforam estruturadas por meio da estrategia do P.I.C.O. (Paciente; Intervencao ou Indicador; Comparacao; Outcome). As estrategias de busca avaliaram as bases de dados MEDLINE, EMBASE, Scielo/Lilacs, Cochrane Library ate fevereiro de 2012 (Apendice). Os artigos selecionados na primeira estrategia de busca foram submetidos a avaliacao critica das evidencias, utilizando-se o escore de Jadad. Posteriormente, foram elaboradas as respostas das recomendacoes – cada referencia bibliografica selecionada apresentava o correspondente grau de recomendacao e forca de evidencia cientifica. Para as recomendacoes finais, as referencias bibliograficas foram atualizadas ate agosto de 2012, redigidas em texto unico pelo coordenador, e submetidas aos coautores em dois turnos, para elaboracao do texto final. Grau de recomendacao e forca de evidencia A: Estudos experimentais e observacionais de melhor consistencia. B: Estudos experimentais e observacionais de menor consistencia. C: Relatos de casos (estudos nao controlados). D: Opiniao desprovida de avaliacao critica, baseada em consensos, estudos fisiologicos ou modelos animais. Objetivo Estabelecer as recomendacoes para o manejo (criterios classificatorios e avaliacao por ressonância magnetica e genetica) das espondiloartrites e para o tratamento da espondilite anquilosante.

Ethnic Influence in Clinical and Functional Measures of Brazilian Patients with Spondyloarthritis

Objective. Spondyloarthritides (SpA) can present different disease spectra according to ethnic background. The Brazilian Registry of Spondyloarthritis (RBE) is a nationwide registry that comprises a large databank on clinical, functional, and treatment data on Brazilian patients with SpA. The aim of our study was to analyze the influence of ethnic background in SpA disease patterns in a large series of Brazilian patients. Methods. A common protocol of investigation was prospectively applied to 1318 SpA patients in 29 centers distributed through the main geographical regions in Brazil. The group comprised whites (65%), African Brazilians (31.3%), and people of mixed origins (3.7%). Clinical and demographic variables and various disease index scores were compiled. Ankylosing spondylitis (AS) was the most frequent disease in the group (65.1%); others were psoriatic arthritis (18.3%), undifferentiated SpA (6.8%), enteropathic arthritis (3.7%), and reactive arthritis (3.4%). Results. White patients were significantly associated with psoriasis (p = 0.002), positive HLA-B27 (p = 0.014), and use of corticosteroids (p < 0.0001). Hip involvement (p = 0.02), axial inflammatory pain (p = 0.04), and radiographic sacroiliitis (p = 0.025) were associated with African Brazilian descent. Sex distribution, family history, and presence of peripheral arthritis, uveitis, dactylitis, urethritis, and inflammatory bowel disease were similar in the 3 groups, as well as age at disease onset, time from first symptom until diagnosis, and use of anti-tumor necrosis factor-α agents (p > 0.05). Schober test and thoracic expansion were similar in the 3 groups, whereas African Brazilians had higher Maastricht Ankylosing Spondylitis Enthesitis Scores (p = 0.005) and decreased lateral lumbar flexion (p = 0.003), while whites had a higher occiput-to-wall distance (p = 0.02). African Brazilians reported a worse patient global assessment of disease (p = 0.011). Other index scores and prevalence of work incapacity were similar in the 3 groups, although African Brazilians had worse performance in the Ankylosing Spondylitis Quality of Life questionnaire (p < 0.001). Conclusion. Ethnic background is associated with distinct clinical aspects of SpA in Brazilian patients. African Brazilian patients with SpA have a poorer quality of life and report worse disease compared to whites.

Diagnóstico e tratamento das lombalgias e lombociatalgias

DESCRICAO DO METODO DE COLETA DE EVIDENCIAS: Reuniao consensual e multidisciplinar para elaboracao do texto com inclusao das citacoes bibliograficas, numa colaboracao das especialidades de reumatologia, ortopedia e traumatologia, neurocirurgia, radiologia, medicina fisica e reabilitacao e patologia da coluna vertebral. A partir de um texto basico referencial elaborado pelo editor medico, os participantes, divididos em cinco grupos de trabalho, geraram, por acrescimos e subtracoes ao texto basico, recomendacoes aprovadas, posteriormente, em plenaria, que permitiram a edicao de um texto preliminar. O documento do consenso foi veiculado pela Internet, para consulta publica, tendo recebido varias sugestoes e comentarios de especialistas no assunto. As propostas foram devidamente avaliadas por uma comissao julgadora e revisora, que selecionou as que foram incorporadas ao texto preliminar. O editor medico, a partir da versao revisada, chegou ao texto final publicado, que recebeu da Biblioteca Nacional o ISBN n° 85-901548-1-5. Uma versao resumida do referido consenso, com algumas adequacoes, foi elaborada em trabalho colaborativo entre o editor medico e a comissao tecnica do projeto diretrizes AMB/CFM. GRAU DE RECOMENDACAO E FORCA DE EVIDENCIA: A: Grandes ensaios clinicos aleatorizados e meta-analises. B: Estudos clinicos e observacionais bem desenhados. C: Relatos e series de casos clinicos. D: Publicacoes baseadas em consensos ou opinioes de especialistas. OBJETIVOS: Oferecer informacoes sobre o diagnostico e tratamento das lombalgias e lombociatalgias. PROCEDIMENTOS: Diagnosticos e terapeuticos para as lombalgias e lombociatalgias.

Evaluation of the association between osteoporosis and postural balance in postmenopausal women

The incidence of osteoporosis has been increasing, as have fractures resulting from falls. Postural balance was evaluated in postmenopausal women with and without lumbar osteoporosis. One hundred and twenty-six postmenopausal women aged 55-65 years were evaluated and separated into two groups according to the bone mineral density values of their lumbar spine: the osteoporosis group and the control group, paired by age (P = 0.219) and physical activity (P = 0.611). There was no difference between the groups (P = 0.139) regarding falls reported in the previous 12 months. Functional mobility was evaluated through the Timed Up and Go Test. Postural balance was evaluated using a portable force platform in standard standing position, with eyes open and closed, for 60s. Muscle strength was evaluated through an isokinetic dynamometer. This study shows that there is no difference in knee muscle strength and functional mobility (P = 0.121), postural balance with eyes open [mediolateral displacement (P = 0.286) and mean velocity of the center of pressure (COP) (P = 0.173)] and with eyes closed [mediolateral displacement (P = 0.163), and the mean velocity of displacement of the COP (P = 0.09)] in both groups. Subjects reporting falls had greater mediolateral displacement (P = 0.028) in both groups. Postmenopausal women aged between 55 and 65 years do not present changes in postural balance irrespective of lumbar osteoporosis. Greater COP mediolateral displacement is related to the occurrence of falls in postmenopausal women in the previous year.

Recommendations on the use of biosimilars by the Brazilian Society of Rheumatology, Brazilian Society of Dermatology, Brazilian Federation of Gastroenterology and Brazilian Study Group on Inflammatory Bowel Disease—Focus on clinical evaluation of monoclonal antibodies and fusion proteins used in the treatment of autoimmune diseases

The Brazilian Societies of Rheumatology (SBR) and Dermatology (SBD), the Brazilian Federation of Gastroenterology (FBG) and the Brazilian Study Group on Inflammatory Bowel Disease (GEDIIB) gathered a group of their respective specialists on the topic of interest to discuss the most relevant issues regarding the clinical use of biosimilar medicines in Brazil. The main aim of that meeting was to prepare a document with recommendations to guide medical specialists and to help the national regulatory and policy-making agencies as concerns the authorization for marketing biosimilars used in autoimmune diseases, such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, Crohns disease, juvenile idiopathic arthritis and ulcerative colitis. In addition to considerations on the typical differences between innovator medicines and biosimilars, the specialists established a set of seven recommendations on regulatory advances related to clinical studies, indication extrapolation, nomenclature, interchangeability, automatic substitution and pharmacovigilance.