Jozelia Rêgo

3º Consenso Brasileiro para pesquisa de autoanticorpos em células HEp-2 (FAN): recomendações para padronização do ensaio de pesquisa de autoanticorpos em células HEp-2, controle de qualidade e associações clínicas

OBJECTIVE: The Third Brazilian Consensus for autoantibodies Screening in HEp-2 cells had as purpose the evaluation of difficulties in the accomplishment of the 2nd Consensus recommendations that took place in the year of 2002, the discussion of strategies for quality control of the assay and the promotion of an update of the clinical associations of the several immunofluorescent patterns. METHODS:Several ANA experts from university centers and private laboratories in different areas in Brazil joined the workshop in Goiânia on 2008 April 13 and 14 with the purpose of discussing and approving the recommendations for standardization, interpretation and use of the test by physicians. Commercial representatives of different ANA slide brands were also invited as listeners to the workshop. RESULTS AND CONCLUSIONS: The 3rd Consensus emphasized the need for quality control in indirect immunofluorescent since there is a considerable heterogeneity of available microscopes and reagents. It also promoted adaptations in the previously approved terminology used to classify the different patterns and finally updated the clinical associations of the several patterns with the purpose of providing guidance for interpretation of the assay by clinical pathologists and assistant physicians.

I Consenso Nacional para Padronização dos Laudos de FAN HEp-2

A analise da presenca de auto-anticorpos feita por imunofluorescencia indireta em celulas HEp-2 constitui-se em um metodo de triagem escolhido na maioria dos laboratorios clinicos. A ausencia de uma nomenclatura definida para a descricao dos laudos tem trazido problemas na utilizacao clinica do teste, pelas dificuldades no controle de qualidade e na padronizacao dos resultados, que, por sua vez, embora similares, recebiam denominacoes diferentes. O I Consenso Brasileiro para Padronizacao dos Laudos de FAN HEp-2 reuniu em agosto de 2000, em Goiânia, diversos especialistas de todo o Brasil. Esses emitiram pareceres em consenso para os distintos padroes: nucleares, nucleolares, citoplasmaticos e aparelho mitotico. Foram feitas recomendacoes sobre os criterios para a leitura de uma lâmina, bem como para relacao entre a diluicao de triagem e o sistema optico utilizado.

Diretrizes para o tratamento da síndrome do anticorpo antifosfolipídeo

The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial and venous thrombosis, gestational morbidity and presence of elevated and persistently positive serum titers of antiphospholipid antibodies. The treatment of APS is still controversial, because any therapeutic decision potentially faces the risk of an insufficient or excessive antithrombotic coverage associated with anticoagulation and its major adverse effects. This guideline was elaborated from nine relevant clinical questions related to the treatment of APS by the Committee of Vasculopathies of the Brazilian Society of Rheumatology. Thus, this study aimed at establishing a guideline that included the most relevant and controversial questions in APS treatment, based on the best scientific evidence available. The questions were structured by use of the PICO (patient, intervention or indicator, comparison and outcome) process, enabling the generation of search strategies for evidence in the major primary scientific databases (MEDLINE/PubMed, Embase, Lilacs, Scielo, Cochrane Library, Premedline via OVID). A manual search for evidence and theses was also conducted (BDTD and IBICT). The evidence retrieved was selected based on critical assessment by using discriminatory instruments (scores) according to the category of the therapeutic question (JADAD scale for randomized clinical trials and Newcastle-Ottawa scale for non-randomized studies). After defining the potential studies to support the recommendations, they were selected according to level of evidence and grade of recommendation, according to the Oxford classification.

Guidelines for the treatment of antiphospholipid syndrome

The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial and venous thrombosis, gestational morbidity and presence of elevated and persistently positive serum titers of antiphospholipid antibodies. The treatment of APS is still controversial, because any therapeutic decision potentially faces the risk of an insufficient or excessive antithrombotic coverage associated with anticoagulation and its major adverse effects. This guideline was elaborated from nine relevant clinical questions related to the treatment of APS by the Committee of Vasculopathies of the Brazilian Society of Rheumatology. Thus, this study aimed at establishing a guideline that included the most relevant and controversial questions in APS treatment, based on the best scientific evidence available. The questions were structured by use of the PICO (patient, intervention or indicator, comparison and outcome) process, enabling the generation of search strategies for evidence in the major primary scientific databases (MEDLINE/PubMed, Embase, Lilacs, Scielo, Cochrane Library, Premedline via OVID). A manual search for evidence and theses was also conducted (BDTD and IBICT). The evidence retrieved was selected based on critical assessment by using discriminatory instruments (scores) according to the category of the therapeutic question (JADAD scale for randomized clinical trials and Newcastle-Ottawa scale for non-randomized studies). After defining the potential studies to support the recommendations, they were selected according to level of evidence and grade of recommendation, according to the Oxford classification.

The influence of physical function on the risk of falls among adults with rheumatoid arthritis

OBJECTIVES Identify fall prevalence in the last 12 months among patients with rheumatoid arthritis (RA) and verify the influence of disease activity and physical function in the risk of falls. METHODS 43 patients with RA participated in this study. The following parameters were evaluated: clinical aspects; fall occurrence in the last 12 months; ESR (mm/h); pain on a visual analogue scale (VAS) ranging from 0 to 10cm; disease activity, measured by the Disease Activity Score 28/ESR (DAS-28/ESR); physical function, assessed by the Health Assessment Questionnaire (HAQ); and risk of falling, assessed by two tests, the 5-time sit down-to-stand up test (SST5) and the timed get up and go test (TUG). RESULTS The fall prevalence in the last 12 months was 30.2% (13/43). The HAQ total score was the independent risk factor that had significant influence on SST5 performance, and the other variables did not succeeded to explain the SST5 variability. HAQ explained 42.9% of SST5 variability (P<0.001, adjusted R(2)=0.429). HAQ total score and ESR had a significant influence on TUG score performance. Together, these two variables explained 68.8% of the total variation in TUG score (adjusted R(2)=0.688). CONCLUSION Patients with RA have high fall prevalence and the functional disability represents the main factor related to falls risk.

Update on antiphospholipid antibody syndrome

Antiphospholipid syndrome (APS) is an autoimmune disease characterized by antiphospholipid antibodies (aPL) associated with thrombosis and/or pregnancy morbidity. Most APS events are directly related to thrombotic events, which may affect small, medium or large vessels. Other clinical features like thrombocytopenia, nephropathy, cardiac valve disease, cognitive dysfunction and skin ulcers (called non-criteria manifestations) add significant morbidity to this syndrome and represent clinical situations that are challenging. APS was initially described in patients with systemic lupus erythematosus (SLE) but it can occur in patients without any other autoimmune disease. Despite the autoimmune nature of this syndrome, APS treatment is still based on anticoagulation and antiplatelet therapy.

The impact of comorbidities on the physical function in patients with rheumatoid arthritis

OBJECTIVES To investigate the association of comorbidities with mobility limitation and functional disability in patients with rheumatoid arthritis and to identify which comorbidity indicator is the most appropriate to determine this association. METHODS Sixty rheumatoid arthritis patients were enrolled in a cross-sectional study for a period of 11 months. Comorbidities were assessed using three indicators: (i) the total number of comorbidities; (ii) the Charlson comorbidity index; and (iii) the functional comorbidity index. Disease activity was assessed using the Disease Activity Score 28. Functional capacity was measured using the Health Assessment Questionnaire, and mobility was measured using Timed Up and Go Test and Five-Times-Sit-to-Stand Test. Statistical analysis was performed using a stepwise log-linear multiple regression with a significance level of 5%. RESULTS In the final model, only comorbidity was associated with mobility limitation. The functional comorbidity index score explained 19.1% of the variability of the Five-Times-Sit-to-Stand Test (coefficient of determination [R(2)]=0.191) and 19.5% of the Timed Up and Go Test variability (R(2)=0.195). With regard to functional disability, the associated factors were comorbidity and disease activity, which together explained 32.9% of the variability of the Health Assessment Questionnaire score (adjusted R(2)=0.329). CONCLUSION Comorbidities were associated with mobility limitation and functional disability in rheumatoid arthritis patients. The functional comorbidity index proved to be an appropriate comorbidity indicator to determine this association.

III Consenso Brasileiro para Pesquisa de Autoanticorpos em Células HEp-2: perspectiva histórica, controle de qualidade e associações clínicas

OBJETIVO: O III Consenso Brasileiro para Pesquisa de Autoanticorpos em Celulas HEp-2 (FAN) objetivou discutir estrategias para controlar a qualidade do ensaio, promover a atualizacao das associacoes clinicas dos diversos padroes e avaliar as dificuldades de implantacao do II Consenso ocorrido no ano de 2002. METODOS: Nos dias 13 e 14 de abril de 2007 participaram do encontro em Goiânia pesquisadores e especialistas de diversos centros universitarios e laboratorios clinicos de diferentes regioes do Brasil, com o proposito de discutir e aprovar as recomendacoes que visam a melhores padronizacao, interpretacao e utilizacao do ensaio pelos clinicos. Foram convidados como ouvintes representantes comerciais de diferentes empresas produtoras de insumos para realizacao do teste de FAN. RESULTADOS E CONCLUSAO: Dada a heterogeneidade de microscopios e reagentes disponiveis no mercado, o III Consenso enfatizou a necessidade do controle de qualidade em ensaios de imunofluorescencia indireta. Foram tambem feitas algumas adequacoes na terminologia utilizada para classificar os diferentes padroes. Finalmente, foi realizada uma atualizacao das associacoes clinicas com finalidade de facilitar cada vez mais o melhor uso do ensaio pelos clinicos.

Recommendations of the Brazilian Society of Rheumatology for the induction therapy of ANCA-associated vasculitis

The purpose of these recommendations is to guide the appropriate induction treatment of antineutrophil cytoplasmic antibody-associated vasculitis (AAV) patients with active disease. The recommendations proposed by the Vasculopathies Committee of the Brazilian Society Rheumatology for induction therapy of AAV, including granulomatosis with polyangiitis, microscopic polyangiitis and renal-limited vasculitis, were based on systematic literature review and expert opinion. Literature review was performed using Medline (PubMed), EMBASE and Cochrane database to retrieve articles until October 2016. PRISMA guidelines were used for the systematic review and articles were assessed according to the Oxford levels of evidence. Sixteen recommendations were made regarding different aspects of induction therapy for AAV. The purpose of these recommendations is to serve as a guide for therapeutic decisions by health care professionals in the management of AAV patients presenting active disease.

A importância de reconhecer a síndrome antifosfolípide na medicina vascular

Resumo A síndrome antifosfolipíde (SAF) é uma doença autoimune sistêmica caracterizada por trombose arterial ou venosa recorrente e/ou morbidade gestacional e pela presença dos anticorpos antifosfolipídeos, podendo apresentar outras manifestações vasculares, como microangiopatia, arteriopatia crônica e SAF catastrófica. Determinados testes laboratoriais para a síndrome (por exemplo, o anticoagulante lúpico) podem sofrer interferência do uso de medicações anticoagulantes, dificultando o diagnóstico. A fisiopatologia da SAF é complexa, sendo enumerados no texto diversos mecanismos patogênicos relacionados à coagulação, ao endotélio e às plaquetas. Por fim, discutimos o tratamento da SAF de acordo com a presença e o tipo de manifestações clínicas, o uso dos anticoagulantes orais diretos e o manejo perioperatório de pacientes com SAF.