Sueli Carneiro

The development of candidate composite disease activity and responder indices for psoriatic arthritis (GRACE project)

Objective To develop new composite disease activity indices for psoriatic arthritis (PsA). Methods Data from routine clinic visits at multiple centres were collected in a systematic manner. Data included all domains identified as important in randomised controlled trials in PsA. Decisions to change treatment were used as surrogates for high disease activity. New indices were developed by multiple linear regression (psoriatic arthritis disease activity score: PASDAS) and empirically, utilising physician-defined cut-offs for disease activity (arithmetic mean of desirability functions: AMDF). These were compared with existing composite measures: Composite Psoriatic arthritis Disease Activity Index (CPDAI), Disease Activity for PSoriatic Arthritis (DAPSA), and Disease Activity Score for rheumatoid arthritis (DAS28). Results 161/503 (32%) subjects had treatment changes. Although all measures performed well, compared with existing indices, PASDAS was better able to discriminate between high and low disease activity (area under receiver operating curves (ROC)) curve with 95% CI: PASDAS 0.773 (0.723, 0.822); AMDF 0.730 (0.680, 0.780); CPDAI 0.719 (0.668, 0.770); DAPSA 0.710 (0.654, 0.766); DAS28 0.736 (0.680, 0.792). All measures were able to discriminate between disease activity states in patients with oligoarthritis, although area under the receiver operating curves (AUC) were generally smaller. In patients with severe skin disease (psoriasis area and severity index >10) both nonparametric and AUC curve statistics were nonsignificant for all measures. Conclusions Two new composite measures to assess disease activity in PsA have been developed. Further testing in other datasets, including comparison with existing measures, is required to validate these instruments.

Patient Global Assessment in Psoriatic Arthritis: A Multicenter GRAPPA and OMERACT Study

Objective. During OMERACT 8, delegates selected patient global assessment (PGA) of disease as a domain to be evaluated in randomized controlled trials in psoriatic arthritis (PsA). This study assessed the reliability of the PGA, measured by means of 0–100 mm visual analog scale (VAS), and the additional utility of separate VAS scales for joints (PJA) and skin (PSA). Methods. In total, 319 consecutive patients with PsA (186 men, 133 women, mean age 51 ± 13 yrs) were enrolled. PGA, PJA, and PSA were administered at enrolment (W0) and after 1 week (W1). Detailed clinical data, including ACR joint count, Psoriasis Area and Severity Index (PASI), and Hospital Anxiety and Depression Scale, were recorded. Results. Comparison of W0 and W1 scores showed no significant variations (intraclass correlation coefficients for PGA 0.87, PJA 0.86, PSA 0.78), demonstrating the reliability of the instrument. PGA scores were not influenced by patient anxiety or depression, but were dependent on PJA and PSA (p = 0.00001). PJA was dependent on the number of swollen and tender joints (p < 0.00001). PSA scores were influenced by the extent of skin psoriasis and by hand skin involvement (p = 0.00001). Joint and skin disease were found not to correlate in terms of disease activity as evidenced by the swollen joint count compared to PASI (r = 0.11) and by the PJA compared to PSA (r = 0.38). Conclusion. PGA assessed by means of VAS is a reliable tool related to joint and skin disease activity. Because joint and skin disease often diverge it is suggested that in some circumstances both PJA and PSA are also assessed.

Elderly skin and its rejuvenation: products and procedures for the aging skin

In the last few decades, there has been a substantial increase in the population of people over 60 years of age. Most of them maintain a good general health and physical activity and fitness. For these individuals there is a good number of dermatologic procedures, medications, and cosmetics that can be prescribed to improve the aspect of skin aging, providing an improvement in their self‐esteem and quality of life as a result of their better look. We will discuss the mechanisms of skin aging, and the procedures and substances used to minimize its deleterious effects, such as sunscreens, estrogens, chemical peels, toxin botulinum, fillers and surgical procedures, among others. The use of makeup and the adverse reactions to cosmetics will also be mentioned.

Superficial mycoses in immunodepressed patients (AIDS)

HIV infection has the capacity to distort the epidemiology and clinical course of infectious diseases, producing atypical manifestations and changing diagnoses. Superficial fungal infections are frequent in HIV-positive/AIDS patients and are no exception. These infections are frequently different in immunodepressed patients (AIDS), with a modified course or exacerbations. This chapter discusses the diagnosis and treatment of superficial mycoses in HIV patients, including cutaneous alterations caused by Candida, dematiaceous fungi agents of phaeohyphomycosis, Malassezia spp, dermatophyte, and filamentous nondermatophyte fungi.

Systemic mycoses in immunodepressed patients (AIDS)

Infectious and noninfectious skin diseases are observed in about 90% of HIV patients, and their incidence increases and is more severe as the immune system weakens. Cutaneous manifestations are considered good clinical predictors for the immunological condition of the patient with AIDS and the introduction of highly effective antiretroviral therapy totally changed the prognosis of the mycoses, among other diseases associated with AIDS, permitting longer survival and acceptable level of quality of life for these patients. This contribution describes the systemic mycoses that are more frequent in the seropositive population, that is, patients with HIV/AIDS, which are cryptococcosis, histoplasmosis, coccidioidomycosis, blastomycosis, paracoccidioidomycosis, sporotrichosis, penicilliosis, and aspergillosis. Their causative agents, mode of transmission, clinics, laboratorial diagnosis and therapy, in the aspects related to immunodepressed patients, are reviewed.

Isomorphic phenomenon of Koebner: Facts and controversies

Heinrich Koebner (1838-1904) presented in a meeting in 1872 and reported in 1877 the emergence of psoriatic lesions following trauma to healthy skin areas of patients with psoriasis. Since then, the Koebner phenomenon has been the subject of research, as it offers a unique opportunity in the investigation of the disease, especially in experimental studies, when this dermatosis may be observed in all its phases. Establishing the differences between Koebner, Wolf, Renbök, reverse Koebner, pseudo-Koebner phenomena, and pathergy is sometimes unclear. We review the various aspects of the Koebner phenomenons clinical description and presentation, pathophysiology, histopathology, reverse phenomenon, therapeutic treatments, and prevention.

Consenso Brasileiro de Espondiloartropatias: espondilite anquilosante e artrite psoriásica diagnóstico e tratamento - primeira revisão

1. Assistente-doutor da Disciplina de Reumatologia do Departamento de Clinica Medica da Faculdade de Ciencias Medicas da Universidade Estadual de Campinas (FCM-UNICAMP). Presidente da Comissao de Espondiloartropatias da Sociedade Brasileira de Reumatologia (SBR). 2. Professor Assistente da Disciplina de Reumatologia da Universidade Federal do Parana (UFPR). Mestre em Medicina Interna. 3. Professor Assistente da Disciplina de Reumatologia da Pontificia Universidade Catolica de Campinas (PUCCAMP). 4. Professor Adjunto, Doutor em Oftalmologia da Universidade Federal de Minas Gerais (UFMG). 5. Professora Adjunta da Faculdade de Ciencias Medicas da Universidade Estadual do Rio de Janeiro (UERJ) e Professora do Programa de Pos-Graduacao em Medicina da Universidade Federal do Rio de Janeiro (UFRJ). 6. Professor Adjunto, Doutor de Reumatologia do Departamento do Aparelho Locomotor da Universidade Federal de Minas Gerais (UFMG). 7. Professor Doutor-Assistente e Coordenador da Unidade de Espondiloartropatias da Disciplina de Reumatologia da Faculdade de Medicina da Universidade de Sao Paulo (FMUSP). 8. Professora Associada e Responsavel pelo Setor de Reumatologia Pediatrica da Universidade Federal de Sao Paulo (UNIFESP). 9. Professor Regente da Disciplina de Reumatologia da Faculdade de Medicina da Pontificia Universidade Catolica do Rio Grande do Sul (PUC-RS). 10. Professor Titular de Reumatologia da Faculdade de Medicina Souza Marques, Rio de Janeiro – RJ. 11. Professora da Disciplina de Coloproctologia da Fundacao Faculdade Federal de Ciencias Medicas de Porto Alegre (FFFCMPA). 12. Assistente-Doutor e Chefe do Grupo de Reumatologia do Instituto de Ortopedia e Traumatologia da FMUSP. 13. Chefe do Servico de Reumatologia e Coordenador da Residencia Medica do Hospital Geral de Fortaleza. 14. Chefe do Departamento de Medicina Interna do Hospital Geral de Goiânia. Doutor em Reumatologia pela FMUSPUniversidade Estadual de Campinas Faculdade de Ciencias Medicas Departamento de Clinica Medica

Gender characterization in a large series of Brazilian patients with spondyloarthritis

An increasing number of women have been diagnosed with spondyloarthritis (SpA) in recent decades. While a few studies have analyzed gender as a prognostic factor of the disease, no studies have addressed this matter with a large number of patients in South America, which is a peculiar region due to its genetic heterogeneity. The aim of the present study was to analyze the influence of gender on disease patterns in a large cohort of Brazilian patients with SpA. A prospective study was carried out involving 1,505 patients [1,090 males (72.4%) and 415 females (27.6%)] classified as SpA according to the European Spondyloarthropaties Study Group criteria who attended at 29 reference centers for rheumatology in Brazil. Clinical and demographic variables were recorded and the following disease indices were administered: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Radiologic Index (BASRI), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), and Ankylosing Spondylitis Quality of Life (ASQoL). Ankylosing spondylitis (AS) was the most frequent disease in the group (65.4%), followed by psoriatic arthritis (18.4%), undifferentiated SpA (6.7%), reactive arthritis (3.3%), arthritis associated to inflammatory bowel disease (3.2%), and juvenile SpA (2.9%). The male-to-female ratio was 2.6:1 for the whole group and 3.6:1 for AS. The females were older (p < 0.001) and reported shorter disease duration (p = 0.002) than the male patients. The female gender was positively associated to peripheral SpA (p < 0.001), upper limb arthritis (p < 0.001), dactylitis (p = 0.011), psoriasis (p < 0.001), nail involvement (p < 0.001), and family history of SpA (p = 0.045) and negatively associated to pure axial involvement (p < 0.001), lumbar inflammatory pain (p = 0.042), radiographic sacroiliitis (p < 0.001), and positive HLA-B27 (p = 0.001). The number of painful (p < 0.001) and swollen (p = 0.006) joints was significantly higher in the female gender, who also achieved higher BASDAI (p < 0.001), BASFI (p = 0.073, trend), MASES (p = 0.019), ASQoL (p = 0.014), and patient’s global assessment (p = 0.003) scores, whereas the use of nonsteroidal anti-inflammatory drugs (p < 0.001) and biological agents (p = 0.003) was less frequent in the female gender. Moreover, BASRI values were significantly lower in females (p < 0.001). The female gender comprised one third of SpA patients in this large cohort and exhibited more significant peripheral involvement and less functional disability, despite higher values in disease indices.

Oral candidiasis in patients with psoriasis: correlation of oral examination and cytopathological evaluation with psoriasis disease severity and treatment.

BACKGROUND Infections are known to trigger and exacerbate psoriasis. Although oral candidiasis is often clinically diagnosed, it is not always confirmed by laboratory tests such as oral cytopathology. OBJECTIVES The aims of this study were to determine the prevalence of oral candidiasis in patients with psoriasis through clinical and cytopathological diagnosis and to investigate the association between oral candidiasis and psoriasis with regards to the severity of the clinical presentation and the type of treatment for psoriasis. METHODS A total of 140 patients with psoriasis and 140 healthy control subjects received an oral examination. Scrapings of the tongue were also obtained for a cytopathological examination. RESULTS The oral examination and the results of the cytopathological smear revealed 37 (26%) cases of candidiasis in the patients with psoriasis and no cases of candidiasis in the healthy control subjects. There was no correlation between the type of psoriasis treatment and the presence of oral candidiasis (P = .616). There was a statistically significant association (P = .033) between the clinical severity of psoriasis and the presence of Candida. LIMITATIONS This study was limited by the small number of subjects and the lack of follow-up to determine the development of psoriasis after treatment for oral candidiasis. CONCLUSIONS The presence of oral candidiasis is higher in patients with psoriasis and it is associated with disease severity. This increased presence of oral candidiasis was apparent despite any type of treatment for the psoriasis. Cytopathology to rule out oral candidiasis should be used in the routine medical workup of patients with psoriasis.

Oral lichen planus: an update on its pathogenesis.

Oral lichen planus (OLP) is a common T cell‐mediated mucocutaneous disease of unknown etiology. A great number of factors have been suggested as relevant to the etiology of this disease. In this article, the authors assemble recent knowledge about the pathogenesis of OLP, discuss some proposed hypotheses, and compare OLP with oral lichenoid lesions.