José Roberto Provenza

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

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.

Combined Therapy (Ultrasound and Interferential Current) in Patients with Fibromyalgia: Once or Twice in a Week?

BACKGROUND AND PURPOSE Combined Therapy (CT) composed of ultrasound and Interferential Therapy has been reported as a cost-effective, local analgesic intervention on tender points in Fibromyalgia (FM). This study aims to investigate the difference between CT applied once a week and twice a week in patients with FM. METHOD Fifty patients with the diagnosis of FM were randomized into two groups (G1 = once a week treatment and G2 = twice a week treatment) with each group containing 25 patients. All eighteen tender points were assessed and treated with CT during each session, over a three-month time period. Interferential Therapy was modulated at 4,000 Hz of current carrier, 100 Hz of amplitude modulated frequency and at a bearable sensorial threshold of intensity. Pulsed ultrasound of 1 MHz at 20% of 2.5 W/cm² was used. For evaluation, the Visual Analogue Scale, Fibromyalgia Impact Questionnaire, Post Sleep Inventory and the tender point count were utilized, and the examiner was blinded to the group assignments. RESULTS G1 and G2 showed a significant improvement in Visual Analogue Scale (p < 0.0001 and p < 0.0005, respectively), Tender Points (p < 0.005 and p < 0.001, respectively), Fibromyalgia Impact Questionnaire and Post Sleep Inventory (p < 0.005 and p < 0.05, respectively). However, there was no significant difference between the two groups in all performed analyses. CONCLUSION There is no advantage in increasing the number of sessions of combined therapy in terms of reducing generalized pain, quality of life and sleep quality for patients with 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.

Ascite por peritonite lúpica: uma forma rara de início do lúpus eritematoso sistêmico

Serositis is commonly seen in systemic lupus erythematosus (SLE). Approximately 16% of patients with SLE have pleural or pericardial involvement. However, peritoneal involvement is extremely rare, and clinically seen in a small group of patients. This is the case report of a 47-year old female with discoid lupus who evolved with systemic manifestations of the disease, characterized by significant abdominal distension and pain, asthenia, weight loss, signs of ascites, and acute non-invasive diarrhea. Exhaustive diagnostic investigation was performed and included laboratory and imaging tests, colonoscopy, and analysis of the ascitic fluid. Besides ruling out the possibility of an infectious, neoplastic, and hemodynamic etiology, the investigation also allowed the confirmation of SLE. Thus, the hypothesis of lupus peritonitis with ascites became viable. The patient was treated with prednisone and chloroquine, with substantial improvement of her condition

A Brazilian Portuguese version of the Revised Fibromyalgia Impact Questionnaire (FIQR): a validation study

The Fibromyalgia Impact Questionnaire (FIQ) was specifically developed to assess disease severity and functional ability in fibromyalgia patients. In 2009, a revised version of the FIQ was published, the FIQR; this version achieved a better balance among different domains (function, overall impact, symptoms). Here, we present the validity and reliability of the Brazilian version of the Revised Fibromyalgia Impact Questionnaire (FIQR). Female fibromyalgia patients (n = 106) completed an online survey consisting of the Short Form 36 (SF-36) questionnaire, the original FIQ, and the Brazilian Portuguese FIQR, which was translated by a standard method. Validity was established with correlational analyses between the FIQR, FIQ, and SF-36 items. Three domains were established for the FIQR (function, overall impact, symptoms), and their contribution for the SF-36 subscales was also scrutinized. The Brazilian FIQR validation process showed that the questions performed in a very similar way to the original English FIQR. The new questions in the FIQR symptoms domain (memory, balance, tenderness, and environmental sensitivity) revealed a significant impact in fibromyalgia (FM) patients. The Brazilian Portuguese FIQR demonstrated excellent reliability, with a Cronbach’s alpha of 0.96. There was a gain on weight of the function domain and a decrease of the symptom domain, leading to a better balance among domains. The FIQR predicted a great number of SF-36 subscales, showing good convergent validity. The Brazilian Portuguese version of the FIQR was validated and found to be a reliable, easy-to-use, and score FM-specific questionnaire that should prove useful in routine clinical practice and FM-related research.

EpiFibro – a nationwide databank for fibromyalgia syndrome – the initial analysis of 500 women

INTRODUCTION Fibromyalgia syndrome (FS) is a common painful condition of the musculoskeletal system that is typically accompanied by several symptoms in other systems. In Brazil, the prevalence of FS is estimated at 2.5%. Here, we present the initial data from Epi-Fibro, a nationwide databank of FS patients seen in public and private settings. OBJECTIVE The aims of this study were to assess how the diagnosis of FS was made, identify a set of clinical domains considered relevant by both clinicians and patients in cases of FS, analyse the impact of disease on patient quality of life, and compare the findings among patients of public and private services. METHODS Based on the results of questionnaires, we analysed data corresponding to the first 500 women in the database. Questionnaires pertaining to demographic and clinical data and the Fibromyalgia Impact Questionnaire (FIQ), which was translated and validated for Brazilian patients, were completed by the clinicians and/or patients. RESULTS Preliminary analysis of the EpiFibro databank revealed that female FS patients in Brazil reported a high impact of disease, as measured by the FIQ, a high prevalence of associated symptoms, and a low degree of education (consistent with the public health care in Brazil used mainly by the underserved). In addition, most patients perceived their pain as diffuse from the onset of disease. CONCLUSION Depression and anxiety were seen as the main triggers of FM symptoms, but a significant proportion of the subjects perceived work strain as the initial trigger.We also observed a delay of a few years in seeking medical help and examination by a rheumatologist.

New guidelines for the diagnosis of fibromyalgia

OBJECTIVE To establish guidelines based on scientific evidence for the diagnosis of fibromyalgia. MATERIAL AND METHODS Evidence collection was performed based on 9 questions regarding the diagnosis of fibromyalgia, structured using the Patient, Intervention or Indicator, Comparison and Outcome (P.I.C.O.), with searches in the main, primary databases of scientific information. After defining the potential studies to support the recommendations, they were graded according to evidence and degree of recommendation.

Associação de osteomielite tibial e pneumonite por tuberculose miliar em paciente com lúpus eritematoso sistêmico

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease, which has great prevalence and uncommon manifestations of opportunistic infectious diseases, mainly due to the multiple abnormalities of the immune system and the immunosuppressive effect of the medications used in its treatment. Patients whit SLE have an increased incidence of tuberculosis, and osteoarticular involvement occurs in 1%-3% of the cases, manifesting as pain, reduction in mobility, and increased osteoarticular volume. The radiographic findings are often nonspecific. Magnetic resonance imaging (MRI) is an useful test to define the severity of bone involvement; however, the etiological diagnosis can only be established by use of synovial fluid or bone cultures or the histological study of the affected areas. Due to the lack of specificity of the findings, there is usually a mean diagnosis delay of 11 months. We report the case of a female patient with SLE and predisposing factors for tuberculosis infection/reactivation. The MRI was important to define bone involvement, and the etiological diagnosis was established by use of bone biopsy. The patient also had lung involvement due to miliary tuberculosis, shown on plain chest radiography and CT scan and confirmed on culture of Mycobacterium tuberculosis in the sputum. There was a 1.5-month delay in beginning therapy, which is considered a short time when compared to the reports in the literature. In conclusion, bone tuberculosis, although rare, should always be remembered as a differential diagnosis of patients with SLE and osteomyelitis, mainly those with history of pulmonary tuberculosis.

Musculoskeletal ultrasound findings in paracoccidioidomycosis

Paracoccidioidomycosis is a fungal infection endemic to South America. The infection is usually asymptomatic and mostly affects the upper and lower respiratory tracts with clinical-radiological dissociation. Joint involvement is rare with no specific pattern or radiological injury. We report a case of paracoccidioidomycosis in which the patients initial symptoms were hoarseness and arthritis. After an ultrasound examination, we performed the differential diagnosis of other noninfectious arthropathies and analysis of the material collected, which revealed infection with the fungus Paracoccidioides brasiliensis.