Joäo Francisco Marques Neto

Methotrexate in the treatment of ankylosing spondylitis.

The authors carried out an open prospective study analyzing methotrexate (MTX) ef®cacy and toxicity in 34 patients with ankylosing spondylitis (AS) for a period of one year. All the patients presented with active axial disease, characterized by in ̄ammatory spinal pain, prolonged morning stiffness, erythrocyte sedimentation rate (ESR) §25 mm, and failure on treatment with non-steroidal anti-in ̄ammatory drugs for a period of more than two years. MTX was taken at a single weekly intramuscular dose of 12.5 mg. Thirty-one patients (91%) concluded treatment. Eighteen patients (53%) were considered responders to MTX; most of them presented peripheral arthritis. Despite clinical improvement, axial measures were unaltered at the end of the study. The mean value of ESR decreased signi®cantly at the end of the treatment (p~0.0001), predominantly in the responders group. Side effects were observed in 23 patients (68%) and included dyspeptic syndrome, transient elevation of liver enzymes, and dizziness. The results of this one year open study suggest that MTX can be an ef®cient drug in the treatment of AS.The authors carried out an open prospective study analyzing methotrexate (MTX) efficacy and toxicity in 34 patients with ankylosing spondylitis (AS) for a period of one year. All the patients presented with active axial disease, characterized by inflammatory spinal pain, prolonged morning stiffness, erythrocyte sedimentation rate (ESR) > or = 25 mm, and failure on treatment with non-steroidal anti-inflammatory drugs for a period of more than two years. MTX was taken at a single weekly intramuscular dose of 12.5 mg. Thirty-one patients (91%) concluded treatment. Eighteen patients (53%) were considered responders to MTX; most of them presented peripheral arthritis. Despite clinical improvement, axial measures were unaltered at the end of the study. The mean value of ESR decreased significantly at the end of the treatment (p=0.0001), predominantly in the responders group. Side effects were observed in 23 patients (68%) and included dyspeptic syndrome, transient elevation of liver enzymes, and dizziness. The results of this one year open study suggest that MTX can be an efficient drug in the treatment of AS.

A Risk Assessment Tool (OsteoRisk) for Identifying Latin American Women with Osteoporosis

AbstractOBJECTIVE: To develop a simple and easy-to-use tool for identifying osteoporotic women (femoral neck bone mineral density [BMD] T-scores ≤−2.5) in Latin America. DESIGN: Retrospective study involving review of medical records. SETTING: Osteoporosis clinics in 6 Latin American countries. PATIENTS: Postmenopausal women ages ≥50 in Latin America who had femoral neck BMD measurements. MEASUREMENTS AND MAIN RESULTS: A risk index was developed from 1.547 patients based on least square regression using age, weight, history of fractures, and other variables as predictors for BMD T-score. The final model was simplified by reducing the number of predictors; sensitivity and specificity were evaluated before and after reducing the number of predictors to assess performance of the index. The final model included age, weight, country, estrogen use, and history of fractures as significant predictors for T-score. The resulting scoring index achieved 91% sensitivity and 47% specificity. Simplifying the index by using only age and weight yielded similar performance (sensitivity, 92%; specificity, 45%). Three risk categories were identified based on OsteoRisk, the index using only age and body weight: high-risk patients (index <=−2; 65.6% were osteoporotic), moderate-risk patients (−21; 8% were osteoporotic). Similar results were seen in a validation sample of 279 women in Brazil. CONCLUSION: Age and weight alone performed well for predicting the risk of osteoporosis among postmenopausal women. The OsteoRisk is an easy-to-use tool that effectively targets the vast majority of osteoporotic patients in Latin America for evaluation with BMD.

Bone mineral density, vitamin D and anticonvulsant therapy

UNLABELLED The aim of this study was to assess bone mineral density and vitamin D metabolism in patients on chronic anticonvulsant therapy. METHODS Sixty-nine men, outpatients on chronic anticonvulsant therapy, who had been treated for at least 5 years, were studied, comparing them to thirty healthy controls. Bone mineral density was measured as well as serum levels of calcium, ionized calcium, alkaline phosphatase, PTH, 25-hydroxycholecalciferol and 1, 25-dihydroxycholecalciferol. RESULTS No differences in bone mineral density, serum levels of vitamin D and intact-PTH were observed between patients and controls. Bone mineral density was not associated with chronic anticonvulsant therapy. CONCLUSION Those adult patients who were on chronic anticonvulsant therapy and who lived in low latitude regions had normal bone mineral density as well as vitamin D serum levels.

Low bone mass density is associated with hemolysis in brazilian patients with sickle cell disease

OBJECTIVES: To determine whether kidney disease and hemolysis are associated with bone mass density in a population of adult Brazilian patients with sickle cell disease. INTRODUCTION: Bone involvement is a frequent clinical manifestation of sickle cell disease, and it has multiple causes; however, there are few consistent clinical associations between bone involvement and sickle cell disease. METHODS: Patients over 20 years of age with sickle cell disease who were regularly followed at the Hematology and Hemotherapy Center of Campinas, Brazil, were sorted into three groups, including those with normal bone mass density, those with osteopenia, and those with osteoporosis, according to the World Health Organization criteria. The clinical data of the patients were compared using statistical analyses. RESULTS: In total, 65 patients were included in this study: 12 (18.5%) with normal bone mass density, 37 (57%) with osteopenia and 16 (24.5%) with osteoporosis. Overall, 53 patients (81.5%) had bone mass densities below normal standards. Osteopenia and osteoporosis patients had increased lactate dehydrogenase levels and reticulocyte counts compared to patients with normal bone mass density (p<0.05). Osteoporosis patients also had decreased hemoglobin levels (p<0.05). Hemolysis was significantly increased in patients with osteoporosis compared with patients with osteopenia, as indicated by increased lactate dehydrogenase levels and reticulocyte counts as well as decreased hemoglobin levels. Osteoporosis patients were older, with lower glomerular filtration rates than patients with osteopenia. There was no significant difference between the groups with regard to gender, body mass index, serum creatinine levels, estimated creatinine clearance, or microalbuminuria. CONCLUSION: A high prevalence of reduced bone mass density that was associated with hemolysis was found in this population, as indicated by the high lactate dehydrogenase levels, increased reticulocyte counts and low hemoglobin levels.

Neurologic Involvement in Scleroderma en Coup de Sabre

Localized scleroderma is a rare disease, characterized by sclerotic lesions. A variety of presentations have been described, with different clinical characteristics and specific prognosis. In scleroderma en coup de sabre (LScs) the atrophic lesion in frontoparietal area is the disease hallmark. Skin and subcutaneous are the mainly affected tissues, but case reports of muscle, cartilage, and bone involvement are frequent. These cases pose a difficult differential diagnosis with Parry-Romberg syndrome. Once considered an exclusive cutaneous disorder, the neurologic involvement present in LScs has been described in several case reports. Seizures are most frequently observed, but focal neurologic deficits, movement disorders, trigeminal neuralgia, and mimics of hemiplegic migraines have been reported. Computed tomography and magnetic resonance imaging have aided the characterization of central nervous system lesions, and cerebral angiograms have pointed to vasculitis as a part of disease pathogenesis. In this paper we describe the clinical and radiologic aspects of neurologic involvement in LScs.

Sporothrix schenckii infection presented as monoarthritis: report of two cases and review of the literature

Septic arthritis demands early diagnosis and correct treatment if the function of the joint is to be restored. Sometimes, as in fungal infection, signs and symptoms may be mild and the diagnosis delayed. Nevertheless, the outcome of fungal arthritis is severe and usually causes joint disability. The authors report two patients with chronic monoarthritis due to Sporothrix schenckii infection diagnosed by synovial fluid cultures. Their clinical presentation, laboratory and image findings, and their treatment and follow-up are analyzed and compared to previously reported cases. These cases illustrate the differential diagnosis of monoarthritis in immunocompetent adults and picture clinical features that could lead to early diagnosis and proper treatment.

The effect of foot orthoses on balance, foot pain and disability in elderly women with osteoporosis: a randomized clinical trial

OBJECTIVE To evaluate the effect of insoles with medial arch support and metatarsal pad on balance, foot pain and disability in elderly women with osteoporosis. METHODS This was a randomized controlled clinical trial. Ninety-four elderly women (>60 years) with osteoporosis in treatment in the outpatient clinic of the Rheumatology Division of UNICAMP were randomly assigned to an intervention group (IG) with foot orthoses or to a control group (CG) without orthoses. The Berg Balance Scale (BBS), the Timed Up and Go test (TUG), the Manchester Foot Pain and Disability Index (MFPDI) and a numeric pain scale (NPS) were assessed at baseline and after 4 weeks. The chi-squared test, Fishers exact test and Mann-Whitney test were applied to compare baseline values between the two groups. Repeated measures of analysis of variance followed by Tukeys test for multiple comparisons and the contrast profile test were used to compare the longitudinal measures. For numeric variable relationship analysis, the Spearman correlation coefficient was used. RESULTS The groups were similar at baseline. Only subjects from the IG displayed improvements in balance (both BBS and TUG), foot pain (NPS) and disability (MFPDI) (P < 0.001). Minor adverse effects were noted. CONCLUSION Foot orthoses were effective for improving balance and for reducing pain and disability in elderly women. Orthoses can be used as an adjuvant strategy to improve balance and to prevent falls in the elderly.

Recomendações sobre diagnóstico e tratamento da esclerose sistêmica

Descricao do metodo de elaboracao das evidencias Os integrantes da Comissao de Esclerose Sistemica 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 propostas e discutidas pela internet, no segundo semestre de 2011. As 15 questoes clinicas consideradas relevantes foram 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 setembro de 2012 (Apendice). Os artigos selecionados na primeira estrategia de busca foram submetidos a avaliacao critica das evidencias, utilizando-se o escore de Jadad. Foram considerados tambem estudos observacionais e series de casos na ausencia de ensaios clinicos randomizados. Foi realizada insercao de estudos relevantes obtidos por busca manual. Posteriormente, foram elaboradas as respostas as perguntas das Recomendacoes, em que 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 dezembro de 2012, redigidas em texto unico pelo coordenador, e submetidas aos coautores em quatro 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 e para o tratamento da esclerose sistemica.

Recommendations for the management and treatment of systemic sclerosis.

Description of the method to elaborate the evidence The members of the Comissao de Esclerose Sistemica da Sociedade Brasileira de Reumatologia (Systemic Sclerosis Commission of the Brazilian Society of Rheumatology, SBR) 2010- 2012 took part in the Evidence Preparation Course given by the Associacao Medica Brasileira (Brazilian Medical Association, AMB) in Sao Paulo in the first semester of 2011. The questions were formulated and discussed via internet in the second semester of 2011. The 15 clinical questions considered to be relevant were structured using the P.I.C.O. method (patient; intervention or indicator; comparison; outcome). The literature search was conducted by searching the databases MEDLINE, EMBASE, SciElo/Lilacs, and the Cochrane Library through February, 2012 (Appendix). Critical assessment of the evidence in the selected articles was performed using the Jadad score. The observational studies and case series were considered for analysis when randomised clinical trials could not be located. A manual search located the relevant studies that were included in the analysis. The answers to the questions included in the Recommendations were refined and elaborated, and all of the selected references exhibited the corresponding grade of recommendation and the strength of scientific evidence. The references were updated through December, 2012, entered into a single file by the coordinator, and sent to the co-authors in four successive rounds for preparation of the final version. Grades of recommendation and strength of evidence A. Most consistent experimental and observational studies. B. Less consistent experimental and observational studies. C. Case reports (uncontrolled studies). D. Opinion that is not substantiated by critical evaluation, based on consensus, physiological studies or animal models. Objective To establish recommendations for the management and treatment of systemic sclerosis.

Crise renal como manifestação inicial de esclerose sistêmica sine scleroderma

Systemic sclerosis sine scleroderma (ssSSc) is a rare disorder, characterised by visceral involvement (usually peripheral vascular, gastrointestinal and pulmonary) in the absence of the characteristic skin fibrosis. The authors describe in this case report the rare occurrence of sclerodermic renal crisis (SRC) as the initial clinical manifestation in a patient with ssSSc.