Eduardo dos Santos Paiva

Characterisation of uveitis in patients with psoriatic arthritis

OBJECTIVE The purpose of this study is to describe the clinical characteristics of uveitis related to psoriatic arthritis (PsA), and also to compare the uveitis in PsA to the uveitis in spondyloarthropathy (SA). METHODS Sixteen patients with uveitis and PsA were evaluated in a tertiary care uveitis clinic. These patients were compared retrospectively to a series of 89 patients with uveitis and SA. RESULTS Eight (50%) of the 16 patients with uveitis had strictly peripheral arthritis, while two (12.5%) had axial only, and six (37.5%) had axial and peripheral arthritis. Patients with uveitis and axial disease were more likely to be male (100% v 38%) and HLA-B27 positive (6 of 6 typed positive v 0 of 3 typed positive) when compared with those with uveitis and peripheral arthritis only. Compared with patients with SA, those with PsA were more likely to have insidious onset (19% v3%), simultaneously bilateral (37.5% v7%), chronic duration (31% v 6%), or posterior (44% v 17%) uveitis. Complications of uveitis were similar in the SA and PsA groups. CONCLUSION Uveitis in patients with PsA was more likely to be insidious in onset, continuous, posterior, and active bilaterally compared with uveitis in patients with SA. Patients with uveitis and axial involvement were more likely to be male and HLA-B27 positive compared with patients with uveitis and peripheral arthritis alone. Patients with seronegative arthritis and uveitis that begins insidiously, lasts longer than six months, is bilateral, or is posterior, should be carefully questioned about the presence of either psoriasis or inflammatory bowel disease.

Consenso brasileiro do tratamento da fibromialgia

Recebido em 06/10/2009. Aprovado, apos revisao, em 24/11/2009. Roberto Ezequiel Heymann e Eduardo dos Santos Paiva declaram ter recebido honorarios da Lilly, Janssen-Cilag, Boehringer, Apsen e Pfizer para palestras e consultoria; Milton Helfenstein Junior recebeu honorarios da Pfizer e Merck Sharp para palestras e consultoria; Daniel Feldman Pollak recebeu honorarios da Lilly, Pfizer e Merck Sharp; Jose Eduardo Martinez recebeu honorarios da Sanofi Aventis para palestras e da Pfizer para palestras e consultoria; Jose Roberto Provenza recebeu honorarios dos laboratorios Roche, Bristol, Ache e Pfizer para participar de pesquisas clinicas com novos farmacos na PUC-Campinas; Marcelo Cruz Rezende declara ter recebido honorarios da Lilly-Boehringer para a participacao em simposios e da Pfizer para ser palestrante e participar de simposios; valerio valim Cristo declara recebimento de honorarios por apresentacao, conferencia ou palestra pela Roche, alem de financiamento para a realizacao de pesquisa, organizacao de atividade de ensino ou comparecimento a simposios pela Lilly, Genzyme, Schering-Plough. os demais autores declararam nao haver conflitos de interesse.1. Coordenador do Ambulatorio de Fibromialgia da UNiFESP e assistente doutor da Disciplina de Reumatologia da UNiFESP2. Professor Assistente da Disciplina de Reumatologia, UFPR. Chefe do ambulatorio de fibromialgia do HC-UFPR3. Assistente doutor da Disciplina de Reumatologia da UNiFESP4. Professor Adjunto da Disciplina de Reumatologia da UNiFESP e chefe do Setor de reumatismos de partes moles da UNiFESP5. Professor titular do Departamento de Medicina da PUC-SP, doutor em Reumatologia pela UNiFESP e diretor da Faculdade de Medicina da PUC-SP6. Professor titular de Reumatologia da PUC-Campinas e chefe do Servico de Reumatologia do Hospital Universitario da PUC-Campinas7. Professora orientadora da pos-graduacao da Faculdade de Ciencias da Saude da UnB e chefe do centro de ambulatorios do Hospital Universitario de Brasilia8. Membro da Sociedade Brasileira de Reumatologia9. Mestre em Medicina pelo instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte, coordenador do Programa de Residencia Medica em Reumatologia e do Ambulatorio de Fibromialgia da Santa Casa de Belo Horizonte10. Ex-presidente da Sociedade Brasileira de Reumatologia, bienio 2007-200811. Professora colaboradora da Faculdade de Medicina da USP, assistente doutora do Servico de Reumatologia e responsavel pelo ambulatorio de Fibromialgia do Servico de Reumatologia do HC-FMUSP12. Responsavel pelo Setor de Reumatologia e Preceptor do programa de Residencia em Clinica Medica da Santa Casa de Campo Grande. Ex-presidente da Sociedade de Reumatologia do Mato Grosso do Sul13. Professor assistente de Reumatologia da Universidade Federal de Ciencias da Saude de Porto Alegre (UFCSPA) e mestre em Clinica Medica pela UFGRS14. Reumatologista com especializacao em Medicina Esportiva do setor de reabilitacao, procedimentos e coluna vertebral pela UNiFESP15. Ex-fellow da Universidade da virginia (EUA), mestre em Educacao e Ciencia e professora da UNiSUL16. Professora adjunto do Departamento de Clinica Medica, chefe do ambulatorio de fibromialgia e chefe do servico de Reumatologia do Hospital Universi-tario da Universidade Federal do Espirito Santo17. Doutora em Reumatologia pela UNiFESP, membro da Sociedade Brasileira de Reumatologia e da Sociedade Brasileira de Clinica Medica18. Membro da Sociedade Brasileira para o Estudo da Dor19. Presidente da Associacao Brasileira de Medicina Fisica e Reabilitacao, professora colaboradora da Faculdade de Medicina da Universidade de Sao Paulo e doutora em Medicina pela FMUSP20. Membro da Associacao Brasileira de Medicina Fisica e Reabilitacao21. Professor titular de Neurologia da Universidade Federal Fluminense (UFF), coordenador do Departamento de Dor da Academia Brasileira de Neurologia (ABN) e do Subcomite de Dor da European Neurological Society (ENS). Membro da Peripheral Nerve Society22. Doutor em ortopedia e Traumatologia pela Faculdade de Medicina da USP, medico Assistente do Grupo de Mao e professor colaborador da FMUSP23. Membro da Sociedade Brasileira de ortopedia e Traumatologia24. Membro da Consultoria Axia.Bio farmacoeconomia e pesquisa em saude25. Diretor executivo do Nucleo de Gestao de Pesquisas da UNiFESP, mestre em Ciencias pela UNiFESP e socio-pesquisador da Axia.Bio

Concomitância de fibromialgia em pacientes com espondilite anquilosante

INTRODUCTION Ankylosing spondylitis (AS) is a chronic inflammatory disease that affects the axial skeletal system, causing pain and functional incapacity. To measure the impact of AS on patients life, questionnaires are used to assess disease activity (BASDAI); functional incapacity (BASFI); and quality of life (ASQoL). Fibromyalgia (FM) is one of the most common causes of generalized pain and can coexist with other diseases; it can be assessed by the Fibromyalgia Impact Questionnaire (FIQ). Few studies have demonstrated correlations between FM and AS. The present study obtained data regarding the epidemiologic profile of patients with AS and FM and evaluated the prevalence of FM in patients with AS. The FM influence on BASDAI, BASFI and ASQoL test scores was assessed. PATIENTS AND METHOD A total of 71 patients with AS, diagnosed according to the modified New York criteria, were studied. Clinical and functional assessment was performed and BASDAI, BASFI and ASQoL tests were applied. Patients with a diagnosis of FM were evaluated through the FIQ. RESULTS Eleven patients met the criteria for FM; thus a FM prevalence of 15% was observed among the patients with AS. FM was more prevalent among women (3.8:1). Age at disease onset (AS) was 27.5 years. The HLA-B27 antigen was positive in most of them (80.4%). When comparing BASDAI, BASFI and ASQoL test means, it was observed that values are significantly higher (P < 0.01) among patients with FM. We concluded that the coexistence of FM can worsen AS activity aspects, as well as functional incapacity and quality of life.

Percepção de estresse e sintomas depressivos: funcionalidade e impacto na qualidade de vida em mulheres com fibromialgia

INTRODUCTION Depression is one of the most frequent psychiatric comorbidities in patients with fibromyalgia (FM), and chronic stress might be one of the triggering events of the characteristic FM symptoms. OBJECTIVES To compare depressive symptoms and stress perception between women with and without FM, in addition to investigate the relationship between those characteristics and the functionality and the impact on the quality of life of those patients. METHODS The study included 20 women with FM (FM group) and 20 healthy women (control group). The following instruments were used: Beck Depression Inventory, Perceived Stress Scale-10, Health Assessment Questionnaire, Fibromyalgia Impact Questionnaire, and Visual Analogue Scale for pain (0-10 cm). RESULTS The FM group showed higher severity of the depressive symptoms (24.10 ± 11.68) and greater perception of stress (25.10 ± 4.82) as compared with those of the control group (10.20 ± 12.78, P < 0.01;and 15.45 ± 7.29, P < 0.01;respectively). A higher incidence of depressive symptoms was observed in the FM group (75%) than in the control group (25%) (χ² = 10.00, P < 0.01). In the FM group, a positive correlation was observed between the depressive symptoms and perceived stress (r = 0.54, P < 0.05), pain (r = 0.58, P < 0.01), impaired functionality (r = 0.56, P < 0.01), and impact on the quality of life (r = 0.46, P < 0.05). In this group there was also correlation between perceived stress and impaired functionality (r = 0.50;P < 0.05). Pain showed no relationship with perceived stress. CONCLUSION The relationship between stress, depression and functionality seems to be part of a complex mechanism, which might affect the quality of life of patients with FM.

Perfil de autoanticorpos e correlação clínica em um grupo de pacientes com esclerose sistêmica na região sul do Brasil

OBJECTIVES: To assess the manifestations of systemic sclerosis (SSc), with an emphasis on the analysis of autoantibodies and their clinical correlations, in a population of patients followed up at the SSc Outpatient Clinics of the Hospital de Clinicas of the Universidade Federal do Parana. METHODOLOGY: Cross-sectional study with 96 patients followed up at the SSc Outpatient Clinics of the hospital between September 2007 and September 2009. RESULTS: Most patients were of the female sex, in their forties or fifties, and the median time of disease was ten years. The limited cutaneous form of SSc was more prevalent. The analysis of the autoantibodies showed the association of anticentromere antibody (ACA) with the following: the limited form of SSc; more advanced age at the time of diagnosis; longer disease time; longer interval between the appearance of the Raynauds phenomenon (RyP) and the first non-RyP symptom; systemic arterial hypertension (SAH); and cardiac conduction blocks. The antitopoisomerase-1 antibody (ATA-1, previously called anti-Scl-70) was more common in the presence of the diffuse form of SSc, active disease, and digital ulcers. The anti-RNA polymerase III antibody (anti-Pol III) correlated with the diffuse form of SSc, disease activity, and synovitis. CONCLUSIONS: This study emphasizes and confirms the important role of autoantibodies in assessing patients with SSc, allowing the correlation between the autoimmune profile of patients with SSc and specific manifestations of the disease

A patient and physician survey of fibromyalgia across Latin America and Europe

BackgroundPatients and physicians from three Latin American (LA) and six European countries were surveyed in order to describe differences in journey to diagnosis, impact, and management of fibromyalgia (FM).Methods900 patients (300 LA; 600 Europe) and 1824 physicians (604 LA; 1220 Europe) were surveyed between October-December 2010 (LA) and February-April 2008 (Europe). Patients and physicians (GP or specialists) completed separate questionnaires, on symptoms, impact, and FM management. Interviews were conducted in local languages. Appropriate rating scales were used throughout. Data were analyzed using cross-tabulations and descriptive statistics. Significance was determined at P < 0.05 (indicated by *).ResultsIn LA versus Europe, patients reported having FM symptoms for longer (100.8 vs. 83.7* months), and taking longer to be diagnosed (42.3 vs. 31.1* months). FM was characterized by multiple symptoms (11.2 vs. 6.9), but more LA patients reported 14 common symptoms*, and rated pain higher on 11-point scale (8.0 vs. 7.2*). LA patients were taking fewer medications (3.3 vs. 4.0). Patients from both regions found common symptoms very/extremely disruptive to their quality of life, but symptoms impacted daily living and ability to work more significantly in LA. Physicians (GPs or specialists) from LA more often considered problems sleeping*, difficulty concentrating*, anxiety*, depression*, numbness/tingling*, and leg cramps* very/extremely disruptive vs. European physicians. Despite headache, heightened sensitivity to touch, difficulty concentrating, and joint pain being experienced by ≥50% of patients from both regions, <15% of PCPs or specialists considered these typical FM symptoms. Patients also considered 12/14 symptoms more disruptive than PCPs or specialists in the same region. However, a higher proportion of PCPs or specialists considered FM to have a strong/very strong impact on aspects of daily living vs. patients within the same region.ConclusionsPatient- and physician-rated disease perception and impact was often higher in LA than in Europe. Patient and physician perspective concerning FM impact and disruption were often misaligned within the same region. Our observations may be representative of cultural differences in stoicism, expression, beliefs, and attitudes to pain perception and management. Better understanding of these complexities could help targeted educational/training programs incorporating cultural differences, to improve chronic care.

Lúpus eritematoso sistêmico complicado por vasculite intestinal e pneumatose intestinal

Gastrointestinal manifestations in systemic lupus erythematosus (SLE) are not uncommon. Non specific symptoms are often observed, such as abdominal pain, nausea, vomiting and diarrhea. On the other hand, pneumatosis cystoides intestinalis, which is characterized by multiple gas-filled cysts located throughout the intestinal wall, is a rare condition in SLE. We describe a case of a 20-year-old man who was admitted with fever, weight loss, headache and arthralgia and had a diagnosis of systemic lupus erythematosus. During his hospital stay, he developed abdominal symptoms that suggested intestinal vasculitis. The computed tomography of the abdomen showed the double halo sign, or target sign and pneumatosis cystoides intestinalis. The patient presented complete recovery after conservative treatment, with intestinal rest and total parenteral nutrition.

Rational treatment of fibromyalgia for a solo practitioner

Fibromyalgia (FM) is a challenging condition, but the management of patients with FM is becoming facilitated by new medications that act in what are thought to be some of most important pathophysiological features in this syndrome. However, it is of pivotal importance that an interdisciplinary approach is used to improve pain, fatigue, sleep and other domains to improve quality of life. Here, we present elements of management that the solo practitioner can tackle, focussing in the formally approved drugs for FM and other drugs commonly used in this condition. Further, the elements of an ideal multidisciplinary team are presented, and on how to incorporate their recommendations for the treatment of FM.

EpiFibro - um banco de dados nacional sobre a síndrome da fibromialgia: análise inicial de 500 mulheres

INTRODUCAO: A fibromialgia (FM) e uma condicao dolorosa do sistema musculoesqueletico, geralmente acompanhada de varios sintomas em outros sistemas, com uma prevalencia no Brasil estimada em 2,5%. Apresentamos os dados iniciais do EpiFibro, um banco de dados nacional de pacientes com FM atendidos em servicos publicos e privados. OBJETIVO: Avaliar como e feito o diagnostico da doenca, identificar um conjunto de dominios clinicos considerados relevantes por medicos e por pacientes com FM, analisar o impacto da doenca na qualidade de vida dos pacientes e comparar os achados entre pacientes de servicos publico e privado. METODOS: Foram analisadas as respostas das primeiras 500 mulheres nesse banco de dados. Esse banco de dados foi baseado em um questionario contendo dados demograficos e clinicos. O Fibromyalgia Impact Questionnaire (FIQ), traduzido e validado para o Brasil, foi preenchido pelos medicos e/ou pacientes. RESULTADOS: Uma analise preliminar do banco de dados EpiFibro revelou que as pacientes com FM no Brasil tem um alto impacto da doenca avaliada pelo FIQ, uma alta prevalencia de sintomas associados, um baixo grau de educacao (um achado que pode ser explicado pelo fato de a saude publica no Brasil ser usada principalmente por aqueles desfavorecidos socialmente) e a maioria percebe a sua dor como sendo difusa a partir do inicio da doenca. CONCLUSAO: Depressao e ansiedade sao percebidas como as principais causas dos sintomas da FM, mas uma quantidade significativa considera o esforco no trabalho como o primeiro gatilho. Ha um atraso de poucos anos em busca de ajuda medica e para chegar ao reumatologista.

Manejo da dor

Aproximadamente, 98% dos pacientes que sao avaliados pelo reumatologista apresentam a dor como queixa principal. Porem, somente em 50% dos casos a dor e bem explicada pelo medico. Ate pouco tempo, a maioria dos livros-texto de reumatologia nao tratava da fisiopatologia e do tratamento da dor nas doencas reumaticas. Esta tendencia esta mudando, com cada vez mais artigos, conferencias e capitulos de livros analisando a dor como sintoma, dissecando os seus aspectos fisiopatologicos e estabelecendo estrategias de tratamento. Esta serie de artigos inclui um editorial chamando a atencao dos reumatologistas para o problema da dor, um artigo da dor na artrite reumatoide (AR), uma serie de artigos no uso de opioides na reumatologia e estudos sobre uma terapeutica nao-farmacologica (acupuntura) e uma nova terapeutica farmacologica.