Fernando de Souza Cavalcanti

Anti-malarials exert a protective effect while Mestizo patients are at increased risk of developing SLE renal disease: data from a Latin-American cohort

OBJECTIVE To examine the role of ethnicity and the use of anti-malarials (protective) on lupus renal disease. METHODS A nested case-control study (1:2 proportion, n = 265 and 530) within GLADELs (Grupo Latino Americano De Estudio de Lupus) longitudinal inception cohort was carried out. The end-point was ACR renal criterion development after diagnosis. Cases and controls were matched for follow-up time (end-point or a comparable time, respectively). Renal disease predictors were examined by univariable and multivariable analyses. Additional analyses were done to determine if the protective effect of anti-malarials persisted after adjusting for intake-associated confounders. RESULTS Of the cases, 233 (87.9%) were women; their mean (s.d.) age at diagnosis was 28.0 (11.9) years and their median (Q3-Q1 interquartile range) follow-up time for cases and controls was 8.3 months (Q3-Q1: 23.5); 56.6% of the cases and 74.3% of the controls were anti-malarial users. Mestizo ethnicity [odds ratio (OR) 1.72, 95% CI 1.19, 2.48] and hypertension (OR 2.26, 95% CI 1.38, 3.70) were independently associated with a higher risk of renal disease, whereas anti-malarial use (OR 0.39, 95% CI 0.26, 0.58), older age at disease onset (OR 0.98, 95% CI 0.96, 0.99) and female gender (OR 0.56, 95% CI 0.32, 0.99) were negatively associated with such occurrence. After adjusting for variables associated with their intake, the protective effect of anti-malarials on renal disease occurrence persisted (OR 0.38, 95% CI 0.25, 0.58). CONCLUSION Mestizo patients are at increased risk of developing renal disease, whereas anti-malarial use protects patients from such an occurrence.

Osteoartrite (artrose): tratamento

DESCRICAO DO METODO DE COLETA DE EVIDENCIAS: Foram utilizados os estudos disponiveis na literatura medica presentes nas seguintes bases de dados, acessiveis atraves da internet: OVID (EBM-Reviews, incluindo-se as bases de dados da Cochrane) e o Medline, de 1966 ate o presente, atraves do Pubmed. Foram selecionados trabalhos de meta-analise e estudos duplo-cegos randomizados, quando presentes. Relatos ou serie de casos foram utilizados quando publicados em jornaisde reconhecida idoneidade. As opinioes dos especialistas presentes foram utilizadas em relacao a terapias nao disponiveis na literatura e que fossem consideradas pela unanimidade dos presentes como importante para o manejo dos pacientes com osteoartrite. Envio previo da bibliografia principal aos participantes. Reuniao para elaboracao do documento. Colocacao do rascunho na internet por dez dias para mudancas. Elaboracao final do documento. 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. OBJETIVOS: Conciliar informacoes e condutas referentes ao tratamento da osteoartrite pelas tres principais especialidades envolvidas, reumatologia, fisiatria e ortopedia. As condutas consensuais para a maioria dos participantes foram entao agrupadas e constam nas recomendacoes deste documento. CONFLITO DE INTERESSE: Os autores Coimbra IB, Pucinelli MLC, Cavalcanti FS e Maciel FMB, declararam vinculo com a Industria Farmaceutica.

Abordagem diagnóstica da tuberculose latente na artrite reumatóide

Despite representing a major advance in rheumatology practice, the use of tumor necrosis factor blockade (anti-TNFs) in the treatment of rheumatoid arthritis (RA) has given rise to a problem that was considered solved in many developed countries, i.e. the heightened risk of reactivation of latent tuberculosis infection (LTBI). The identification of cases of LTBI has thus been made obligatory prior to starting any anti-TNF treatment. The cutaneous tuberculin test (PPD) is not the ideal screening test for this group of patients. Low specificity, cross-reactivity with vaccine antigens and other exogenous microorganisms coupled to a defect in the cell-mediated component of the immunological response account for the inadequacy of PPD as a screening tool in this subset of patients. Assays using the detection of in vitro IFNg production by peripheral blood mononuclear cells stimulated by specific antigens (ESAT-6 and CFP-10), which are found neither in the BCG vaccine nor in other micro-organisms in the environment should perform better than the PPD, owing to a presumed higher specificity as well as to correlation with indirect measures of exposure to Mycobacterium tuberculosis besides decreased cross-reactivity determined by prior BCG vaccination and/or other infections.

Management of rheumatoid diseases: the Brazilian perspective

Management of patients with inflammatory chronic rheumatic diseases in Brazil is based on the perception of the physician’s ability to control inflammation and prevent joint damage, but not on the impact of the knowledge of the disease and in living with it. There is a cultural myth that rheumatic diseases are not curable, among not only patients and relatives but doctors and health care personnel. While ‘baby boomers’ age and live longer than the previous generations, the Brazilian health care system is unprepared to meet their special needs. Health care is still not considered as an economic activity by most physicians and the government. The prevalence rates for RA range from 1.0% in the North to 0.57% in the North-east, 0.6% in the Mid-west and 0.2% in the South-east [1]. RA is managed in the well-known pyramid strategy, which is based on longterm treatment with drugs with very little patient participation. Its treatment is guided by (i) the status of the joint; (ii) the degree of disease activity; (iii) age, sex, occupation and family responsibilities; (iv) the results of previous treatment [2]; and (v) socio-economic factors in both urban and rural communities in Brazil. Patients with rheumatic diseases face many barriers: access to medical services because of the reduced number of rheumatology units; few medical specialists [around 2000 rheumatologists already registered at the Brazilian Society of Rheumatology (BSR)] for a population of about 190 000 000 people [3]; inadequate medical or public transportation; little availability of free medication, except in rich areas, etc. and inequitable medical distribution, e.g. more doctors in developed areas in the South-east and few in the developing north where more resources are needed, with a similar pattern of distribution for rheumatologists (Table 1) [4, 5]. The informed patient has a positive outlook and is better able to handle his or her disease, because their knowledge comprises aspects of the diseases that are important to patients but have not been previously addressed. For instance, fatigue is a symptom that patients consider to be most debilitating. Therefore, management merits detailed discussion about its assessment on limitation and quality of life. In developing countries, the assessment of health care programmes is difficult because of the changes implemented in the Health Ministry related to political change. This scrutiny is crucial for most chronic rheumatic diseases with physical disability. The gaps between regions, i.e. cultural, political and educational, prove to be problematic in extending a global, unique health programme and also for the management of diseases, as well as the communication between patient and physician. Sometimes a doctor’s decision takes precedence over the patient’s wishes. Developed regions can exert more influence to receive support from the government and also from the pharmaceutical companies. Of late, it has become crucial to show whether a therapy benefits not only the disease activity and severity but also the patient’s health-related quality of life. There has been a trend towards health promotion worldwide rather than prevention of disease, which implies that the direction of the management lies with the patient, i.e. patients draw their perception of being ill from the various components of the disease (symptoms, beliefs about health, duration, etc.). Acceptance of the illness is an important point. Several other aspects of the patient’s perspective of the disease—such as finances, health care system, educational level of the patient and cultural aspects— differ from place to place and even within the same region in Brazil. Importantly, each component of the disease affects the perception of one aspect of the disease and they together form the patients’ view of their disease. A patient’s increased knowledge of this process will improve the adherence to treatment and therefore the prognosis. Clinicians in Brazil face limitations in their ability to diagnose and treat diseases, despite a free universal national health system. In the metropolitan area of Recife in the North-east of Brazil (3 000 000), there are four outpatient clinics and one rheumatology unit at the Universidade Federal de Pernambuco with a waiting list of 10 months for the first consultation compared with 4 months in the South. Contemporary management of some rheumatic diseases (RA, SLE, etc.) represents a tremendous challenge for rheumatologists: the best equipped medical centres are concentrated in the South and South-east, especially in the metropolitan areas and in various capitals of states in other regions. Thus, few patients in the other areas receive adequate management from rheumatologists, physiotherapists and occupational therapists. As a result of applying less effective therapies, functional

First Latin American clinical practice guidelines for the treatment of systemic lupus erythematosus: Latin American Group for the Study of Lupus (GLADEL, Grupo Latino Americano de Estudio del Lupus)–Pan-American League of Associations of Rheumatology (PANLAR)

Systemic lupus erythematosus (SLE), a complex and heterogeneous autoimmune disease, represents a significant challenge for both diagnosis and treatment. Patients with SLE in Latin America face special problems that should be considered when therapeutic guidelines are developed. The objective of the study is to develop clinical practice guidelines for Latin American patients with lupus. Two independent teams (rheumatologists with experience in lupus management and methodologists) had an initial meeting in Panama City, Panama, in April 2016. They selected a list of questions for the clinical problems most commonly seen in Latin American patients with SLE. These were addressed with the best available evidence and summarised in a standardised format following the Grading of Recommendations Assessment, Development and Evaluation approach. All preliminary findings were discussed in a second face-to-face meeting in Washington, DC, in November 2016. As a result, nine organ/system sections are presented with the main findings; an ‘overarching’ treatment approach was added. Special emphasis was made on regional implementation issues. Best pharmacologic options were examined for musculoskeletal, mucocutaneous, kidney, cardiac, pulmonary, neuropsychiatric, haematological manifestations and the antiphospholipid syndrome. The roles of main therapeutic options (ie, glucocorticoids, antimalarials, immunosuppressant agents, therapeutic plasma exchange, belimumab, rituximab, abatacept, low-dose aspirin and anticoagulants) were summarised in each section. In all cases, benefits and harms, certainty of the evidence, values and preferences, feasibility, acceptability and equity issues were considered to produce a recommendation with special focus on ethnic and socioeconomic aspects. Guidelines for Latin American patients with lupus have been developed and could be used in similar settings.

Uma nova era

As principais alterações percetíveis são: i) estar disponível apenas online; ii) aceitar contribuições intelectuais apenas em inglês; iii) usar somente a denominação em inglês – Global Economics and Management Review; iv) abandonar o acrónimo EGG/GEMR, escolhendo GEMRev; v) internacionalizar verdadeiramente o conselho editorial e do corpo de revisores. No entanto, a principal mudança será impulsionada por alguns ajustamentos no âmbito e na política da revista, os quais passarão a ter a seguinte redação:

Terapia com Células-Tronco: Esperança ou Novo Marketing?

apresentando os resultados,nacionais e internacionais, desta nova e valiosa ferramentano manuseio de doencas reumatologicas graves e refratariasa terapia tradicional, especialmente no lupus eritematososistemico, na artrite reumatoide e na esclerose sistemica,um momento para reflexao desse procedimento.Em junho deste ano foi realizado na Europa um plebiscitopara o uso da terapia com celulas-tronco. Anteriormente,ocorreu um amplo debate com discussao do significadodesse novo manuseio terapeutico, nos diversos veiculos decomunicacao. Em muitos paises nao foi aprovado o uso decelulas-tronco embrionarias, especialmente porque naoestavam suficientemente claras as implicacoes eticas devidas,por exemplo, a globalizacao de espermatozoides tornandopossivel e questionavel esse tratamento, como tambem apropria expressao genetica nao definida nas celulasembrionarias (doencas auto-imunes, malignidades, etc.) efinalmente o uso prematuro dessa nova terapia pode colocar

CE-43 Factors associated with neuropsychiatric involvement in 1193 latin american patients with systemic lupus erythematosus

Introduction Neuropsychiatric (NP) manifestations in SLE are a major cause of morbidity, mortality and long term consequences. Factors related to their occurrence in patients with short disease duration, both early in the course of the disaease and during follow up have not been clearly established. Purpose To identify disease and non-disease related factors associated with NP manifestations in early SLE. Methods We included 1193 patients from the GLADEL inception cohort free of NP involvement at cohort entry. We examined the relationship between socio-demographic, clinical and laboratory data as well as disease activity and damage with NP involvement during follow-up. Data were recorded in ARTHROS database. We excluded all the secondary NP manifestations (metabolic, drug induced, infectious, etc). Statistical methods The time from cohort entry to first NP manifestation was examined using a Cox proportional hazard regression model. Patients without NP manifestations were censored at last study visit. Independent factors associated with NP involvement were identified using a multivariable Cox regression model. Variables included in the final model were selected using a backward selection algorithm with α-level to stay in the model set to 0.05. Results are summarised as hazard ratios with 95% confidence intervals. Results During a median follow-up time of 52 months, 238 (20 %) patients had NP involvement. The cumulative incidence estimate of NP involvement at 1, 3 and 5 years was 8.3%, 17.8% and 24.7%, respectively. In the univariable analysis some variables like ethnic origin were found to be more frequent in mestizos as compared to patients in the other ethnic groups. Factors independently associated with NP manifestations during follow up are listed in Table 1. Conclusions There are both disease and non-disease related factors that are clearly associated with NP manifestations. Patients of Mestizo background, those with myositis and those with hemolytic anaemia are at higher risk of developing NP. Features Predictive of the Occurrence of NP Manifestations by Multivariable Cox regression model Abstract CE-43 Table 1 Multivariate Model for Neurological Manifestations During Follow-Up Variable Parameter Estimate Standard Error Chi- Square p-value Hazard Ratio represents Hazard Ratio 95% CI Hazard Ratio 0.53132 0.14438 13.5421 0.0002 Mestizo vs. White 1.701 1.282 2.258 Etnia (African Latin American) 0.16647 0.22746 0.5357 0.4642 ALA vs. White 1.181 0.756 1.845 Etnia (Other) 0.31590 0.42454 0.5537 0.4568 Other vs. White 1.371 0.597 3.152 Disease Duration at Cohort Entry (Up to 6 Months) −0.32679 0.20764 2.4769 0.1155 Up to 6 Months vs. Entered at Diagnosis 0.721 0.480 1.083 Disease Duration at Cohort Entry (6 to 12 months) −0.32704 0.20726 2.4898 0.1146 6 to 12 Months vs. Entered at Diagnosis 0.721 0.480 1.082 Disease Duration at Cohort Entry (13 to 24 months) −0.44389 0.19168 5.3629 0.0206 13 to 24 Months vs. Entered at Diagnosis 0.642 0.441 0.934 Myalgias/Myositis 0.60551 0.16169 14.0235 0.0002 Yes vs. No 1.832 1.335 2.515 Pneumonitis 0.90663 0.42076 4.6429 0.0312 Yes vs. No 2.476 1.085 5.648 Shrunk lung 0.88727 0.41648 4.5387 0.0331 Yes vs. No 2.428 1.074 5.493 Hemolytic Anemia 0.48776 0.18645 6.8436 0.0089 Yes vs. No 1.629 1.130 2.347

Mycobacterium Tuberculosis in New Biologic Era

The use of biologic drugs for treating inflammatory joint diseases was approved at the end of last century. Several cases of active lung and extra-pulmonary tuberculosis (TB) were reported at the beginning, and led to creating mandatory screening for latent tuberculosis infection (LTBI) before initiating the treatment with them. The purified protein derivative (PPD) test is the test of choice for diagnosing LTBI, but it has limited sensitivity and specificity, especially in the tropical area. Furthermore, patients with autoimmune diseases have a low frequency of positive skin test compared to patients who do not. Therefore, tests using Interferon Gamma Release Assays (IGRAs) have been carried out with a view to their use in assisting to diagnose LTBI. This chapter places tuberculosis and latent tuberculosis infection (LTBI) in a world context; recounts the origins of the two main tests for detecting LTBI and ant-TNF; evaluates their effectiveness as seen today bearing in mind the incidence of active TB in any given country; and makes proposals for their optimum use including when IGRAs might be used most appropriately.

Microbial Agents – Parasites

Intestinal parasites infections caused by a variety of worms are very common in low-income people without access to sewage and treated water. Contamination occurs in various forms and the main one is the intake of contaminated food or water and through the skin by small wounds. The host response will be different according to the place of parasite replication: intra or extracellular. Usually the musculoskeletal symptom develops within a period of a few days after the intestinal infection. And the clinical manifestations are more likely similar to those seems in Spondiloarthropathies. It is more frequent in children and adolescent, and a slight prevalence for female. Many parasites are able to bypass the host’s immune system, and parasitic disease is the prototype of chronic infection in humans. Persistent parasites have the capacity to release large quantities of antigens, inducing a variety of immunologic reactions.