Advances in Rheumatology最新文献

Background: Cognitive impairment (CI) is a significant problem in systemic lupus erythematosus (SLE) patients. In recent years, total cerebral small vessel disease (CSVD) burden scores have had substantial value in predicting cognitive impairment. However, its application in treating concurrent cognitive impairment in SLE patients is unclear. To explore the relationship between total CSVD burden scores and cognitive dysfunction in SLE patients and to analyze its predictive value.

Methods: The Montreal Cognitive Assessment (MoCA) score was used to evaluate the cognitive function of 50 patients with SLE, and the total load score of patients with CSVD was analyzed via magnetic resonance imaging (MRI). Multivariate regression was used to evaluate the relationship between total CSVD burden scores and cognitive dysfunction, and the predictive value of total CSVD burden scores was assessed.

Results: Multivariate logistic regression analysis revealed that years of education (OR = 0.975, 95% CI [0.952-0.998], P = 0.035), neuropsychiatric systemic lupus erythematosus (NPSLE) (OR = 4.152, 95% CI [2.158-7.990], P < 0.001), and the CSVD total burden score (OR = 3.884, 95% CI [0.840-0.928], P < 0.001) were independently associated with cognitive impairment in SLE patients. The results of the ROC curve analysis revealed that the area under the curve (AUC) of the CSVD total burden score for the prediction of cognitive impairment in SLE patients was 0.885.

Conclusions: Years of education, NPSLE score, and total CSVD burden score are closely related to the occurrence of cognitive impairment in SLE patients. In particular, the total CSVD burden score is beneficial for the prediction of cognitive impairment.

Clinical trial number: Not applicable.

Trial registration: Not applicable.

The article "Brazilian Recommendations for the Management of Tuberculosis Infection in Immune-Mediated Inflammatory Diseases" by Viviane de Souza et al. presents important discussions on the subject; however, the recommendation for annual repetition of the TST/IGRA test for three years and after medication changes raises considerable concerns. This approach may lead to overdiagnosis and overtreatment of latent tuberculosis infection (LTBI). Frequent false-positive results in retests can result in unnecessary antibiotic use, contributing to bacterial resistance, a problem of global significance. The recommendation, considered to have a moderate level of evidence, is subject to criticism. Arguments used to support retesting, such as high conversion rates of tests after one year, reports of tuberculosis cases despite negative screenings being attributed to false negatives, and reliance on other sources with lower levels of evidence, do not constitute sufficient evidence to confirm tuberculosis infection or justify the recommendation. On the other hand, there is evidence that has not been considered in the discussion against the recommendation for retesting, indicating that this practice may increase the risk of diagnosing false-positive infections, leading to overtreatment without clinically proven benefits. Potentially harmful interventions should not be implemented without solid evidence to support them. In this letter to the editor, we briefly discuss this recommendation and the arguments against its implementation, highlighting its associated risks.

Background: Myocardial fibrosis is an important adverse prognostic marker, however; determinants of myocardial fibrosis in immune-mediated inflammatory diseases (IMIDs) remain poorly defined. We aimed to identify determinants of myocardial fibrosis in patients with IMIDs, as measured by cardiovascular magnetic resonance (CMR) extracellular volume (ECV).

Methods: Cross-sectional study of 116 patients with IMIDs undergoing clinical CMR at Manchester University NHS Foundation Trust. IMIDs included rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis (SSc), ankylosing spondylitis, psoriatic arthritis and vasculitis. CMR included pre- and post-contrast T1 mapping to measure myocardial ECV, with same day blood sampling. Determinants of ECV were investigated with univariable and multivariable linear regression.

Results: ECV varied significantly according to IMID diagnosis (ANOVA F statistic 2.80, P = 0.015); ECV was higher in patients with SSc compared to other IMIDs. Major determinants of ECV as a continuous variable were SSc, smoking and body mass index (BMI); regression coefficients 3.33 (95% confidence interval 0.82-5.84), 3.08 (0.73-5.43), and - 0.19 (-0.29 - -0.09) respectively, P < 0.01 (SSc, smoking and lower BMI were associated with increased ECV). Approximately a quarter of the variability in ECV could be explained by these predictors (optimism adjusted R² 0.265).

Conclusion: SSc is associated with a higher burden of myocardial fibrosis compared to other IMIDs. In patients with IMIDs, independent determinants of myocardial fibrosis were presence of SSc, smoking and BMI. Importantly, participants underwent CMR for clinical indications and may not be representative of IMID populations in the community.

Objectives: Fibromyalgia (FM) is a relevant comorbidity in immune-mediated rheumatic diseases (IMRD). Immune mechanisms have been postulated to trigger FM, potentially leading to distinct clinical features compared to FM occurring without IMRDs. This study aims to provide a comprehensive comparison of FM characteristics in patients with and without concomitant IMRD and to evaluate the differences in diagnostic FM criteria between the two groups.

Methods: A comprehensive dataset of clinical, psychosocial, and sleep variables, along with validated questionnaires, was prospectively collected from 341 patients with chronic musculoskeletal pain syndromes who participated in a rheumatology-led, two-week multimodal inpatient program at the University Hospital of Lausanne between 2018 and 2024. Participants were included if they met either the Fibromyalgia Rapid Screening Tool (FiRST) or the American College of Rheumatology (ACR) 2010 criteria for FM. The disease activity of the underlying IMRD was assessed by two rheumatologists. Data were separately analyzed in two cohorts: one fulfilling the FiRST criteria and the other fulfilling the ACR 2010 criteria.

Results: Among the participants, 153 patients met the FiRST criteria, of whom 34 also had a history of clinically diagnosed IMRD. Similarly, 149 patients fulfilled the ACR 2010 criteria, with 32 of them also having IMRD. The most common IMRDs were HLA-B27-negative spondyloarthritis (53%), Sjögren's syndrome (16%), HLA-B27-positive spondyloarthritis (9%), psoriatic arthritis (9%), seronegative rheumatoid arthritis (9%), and seropositive rheumatoid arthritis (3%). In 88% of patients with IMRD, the disease was considered inactive. No significant clinical or epidemiological differences were found between FM patients with or without IMRD in either the FiRST or ACR 2010 cohorts, except for a higher prevalence of enthesopathies and childhood pain in patients with concomitant IMRD. FM patients with IMRD had slightly lower FiRST scores, and FiRST-positive IMRD patients showed a better short-term response to the multimodal program, particularly in FABQ-work, BPI-interference, and Pain Catastrophizing Scale scores. However, no significant difference was observed in the Pain Disability Index (PDI) three months post-program.

Conclusion: HLA-B27-negative spondyloarthritis and Sjögren's syndrome were the most common concomitant IMRDs in this FM cohort. FM patients with and without IMRD exhibited similar clinical and epidemiological features, suggesting a common pathophysiological background. The FiRST criteria, which emphasize central hypersensitization rather than diffuse pain, appear to be a suitable tool for detecting FM in IMRD patients. This may be particularly useful in cases where enthesial pain might interfere with FM diagnosis, and vice versa.

Background: Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in childhood, but its outcomes are still difficult to determine. We aimed to obtain outcome measurements of disease activity, functional capacity, disease damage, and therapeutic response, at one-year follow-up study on a real-life basis.

Methods: An observational JIA cohort from two referral centers for pediatric rheumatology in Brazil Pediatric Rheumatology Centers was carried out over a period of one year. Clinimetric validated outcome measurements were applied over four visits. Multivariable logistic regression was performed to evaluate baseline variables associated with the following outcomes after one year of follow-up: disease activity, Minimal Disease Activity (MDA), disease flare, remission on medication and remission off medication.

Results: A total of 127 patients were included in the study. Eighty-three (65.4%) were females, and median time to diagnosis was 6.0 months. JADAS71 and CHAQ improved during follow-up (mean Vbaseline 7.05 ± 9.3 vs. V52 3.52 ± 8.4; 0 ± 0.5 vs. 0.14 ± 0.4, p < 0.001, respectively) as well as JIA-ACR 30, 50, 70 and 90 (Vbaseline 79.8% vs. V52 88.8%; 71.4% vs. 84.1%; 59.7% vs. 77.6%; 49.6% vs. 69.2%, p < 0.05, respectively). Inactive disease was present in 33% of patients at baseline and in 67.9% at V52 (p < 0.001). Remission on medication, remission off medication and MDA were present in 46%, 11%, and 80.6% of patients at V52, respectively. Extra-articular and articular damage were not common at baseline (0.3 ± 0.7 and 1.1 ± 3.4 respectively) and did not decrease significantly during the period of the study. The presence of active joints 46/101 (45.5%) at baseline reduced the chance of the patient achieving remission off medication at the last visit by 84% (OR = 0.16; CI 95% from 0.03 to 0.91, p = 0.039).

Conclusion: This study showed improvement in clinimetric outcome measurements and therapeutic responses in an inception cohort of JIA patients. The presence of active joints at baseline is related to not achieving remission at last visit. Long-term prospective and multicenter studies are needed to better assess the outcome of JIA and the differences among JIA subtypes.

Background: Takayasu arteritis (TAK) presents as systemic vasculitis. Imaging is crucial for the diagnosis and evaluation of TAK, but the rational selection of imaging methods and interpretation of imaging results are major challenges in clinical practice, which can affect treatment decisions. This guideline aims to establish standardized protocols for selecting imaging modalities (as well as interpreting their findings) in TAK.

Methods: Relevant clinical questions were formulated by an expert panel. Systematic reviews of evidence published from database establishment to 31 October 2023 were done. The grading system set by the Oxford University Evidence-Based Medicine Center was employed to assess the quality of evidence. Recommendations were developed through consensus using the Delphi method.

Results: Seventeen recommendation statements were developed based on evidence summaries and consensus. The first four recommendations focused on overarching principles. Recommendations 5 to 14 covered the advantages and disadvantages of different imaging modalities, as well as the selection of imaging modalities in the diagnosis and evaluation of TAK, including ultrasound (three statements), magnetic resonance angiography (two), computed tomography angiography (two), positron emission tomography/computed tomography (two), and digital subtraction angiography (one). Recommendations 15 to 17 focused on the selection of imaging methods for special populations and organ perfusion.

Conclusion: These recommendations could help to standardize the use of imaging modalities by clinicians in the diagnosis and evaluation of TAK.

Clinical trial number: Not applicable.

Background: Due to the rarity of relapsing polychondritis (RP), we described the demographic, clinical, treatment, outcomes, and comorbidities of patients with RP from our tertiary service. Additionally, a literature review was conducted.

Methods: A total of 47 Brazilian patients with RP between 2000 and 2024 were analyzed. All patient data were collected from pre-parametrized and pre-standardized electronic medical records. A literature review using PubMed with "relapsing polychondritis" as the search term included 25 articles after applying the strict exclusion criteria.

Results: A total of 47 patients were evaluated. The median age was 40 (34-51) years, with a female-to-male ratio of 1.4:1, and 89.4% were of white ethnicity. The median time from symptom onset to diagnosis was 39 months and the median follow-up duration was 7 years. Ear cartilage biopsy was performed in 12.8% of cases. The clinical manifestations included auricular chondritis, arthralgia, and ocular involvement. Approximately half of the patients had hypertension and dyslipidemia, one-third had diabetes mellitus, and one-fifth had hypothyroidism. Tracheostomy and cochlear implantation were required in 12.8% and 6.4% of the patients, respectively. Disease outcomes showed that 46.8% of patients were in remission, 29.8% had active disease, and 25.5% were controlled with immunosuppressive therapy. Mortality occurred in 6.4% of the cases. In the literature review, 25 studies were analyzed, most of which originated in Asia. Studies have reported the classical manifestations of RP, such as auricular chondritis, arthritis, and ocular involvement. The median age of the patients with RP was similar across studies, averaging 46.4 years, with a predominance of female patients. A comparison with the literature showed consistency in clinical manifestations, particularly auricular chondritis and septum nasal chondritis, although few studies have explored comorbidities, disease evolution, and outcomes.

Conclusions: The reviewed articles described classical clinical manifestations, but few articles reported data on other manifestations and comorbidities that can occur in RP. Our study provided new insights by mapping symptom evaluations, thereby enhancing the understanding of disease evolution. Understanding and characterizing RP will allow for better assistance in its diagnosis and follow-up.

Systemic sclerosis (SSc) is an autoimmune connective tissue disorder that can cause generalized inflammation and is characterized by fibrosis of the skin, organs, and vasculopathy. Limited SSc is more common and typically associated with a milder disease course, whereas diffuse SSc, although less common, is linked to a higher mortality rate due to more frequent visceral organ involvement. One of the most common complications of SSc is interstitial lung disease (ILD). ILD is characterized by fibrosis, scarring, and inflammation of the lungs. ILD has a 30% prevalence and a 40% 10-year mortality in patients with SSc worldwide. Hospitalizations for SSc from 2002 to 2020 were obtained using the National Inpatient Sample (NIS), an all-payer administrative database that captures 97% of hospital discharges in the United States. The primary aim was to evaluate whether inpatient mortality, length of stay (LOS), and hospital cost differed if SSc patients had underlying ILD. We estimated multivariable logistic regression and log-normal models controlling for age, biological sex, race/ethnicity, income, and hospital setting. ILD was associated with 88% greater adjusted odds of inpatient mortality (aOR 95% CI: 1.53 to 2.31, p < 0.001), 15% longer stays (aOR 95% CI: 1.04 to 1.28, p = 0.001), and 33% higher adjusted hospital costs (aOR 95% CI: 1.26 to 1.40, p < 0.001). These findings suggest that SSc-ILD has a significant impact on hospitalization outcomes.

Background: The coexistence of dermatomyositis (DM)/clinically amyopathic DM (CADM) and psoriasis has been infrequently documented in the literature. Consequently, this study aimed to analyze this entity from our tertiary center and review the relevant literature.

Methods: This retrospective observational cross-sectional study and case series included patients with DM/CADM and psoriasis between 1998 and 2024. A literature review was also conducted.

Results: Nine of 331 patients with DM (n = 265)/CADM (n = 66) had psoriasis; six were female, and all were of white ethnicity. The median age at DM diagnosis was 38 years (range: 18-78), and at psoriasis diagnosis was 43 years (range: 18-81), with a median interval of four years between diagnoses. The follow-up revealed that six patients were discharged, two died, and one continued follow-up. The primary comorbidities included systemic arterial hypertension (n = 3) and diabetes mellitus (n = 3). Four patients presented with varicella zoster (n = 1) or pulmonary tuberculosis (n = 3). Regarding the literature review, 15 articles reported a total of 17 cases of overlapping DM/CADM and psoriasis. However, variability was observed in the DM/CADM diagnostic criteria. The mean age at DM diagnosis in the literature was 32.3 years (range: 2-59), whereas for psoriasis, it was 31 (7-63) years. Female patients were predominant.

Conclusion: This investigation identified the coexistence of DMPs, with a median age of 38 years for DM and 43 years for psoriasis. The variability in the diagnostic criteria underscores the necessity for standardized approaches to enhance patient management.

Objective: To evaluate the effectiveness of intra-articular injections (IAIs) with triamcinolone hexacetonide (TH) combined with a progressive resistance exercise program (PREP) in improving pain, function, muscle strength, and quality of life in elderly patients with knee osteoarthritis (OA).

Methods: Fifty-nine elderly individuals with knee OA were randomized into three groups: IAI with TH (IAI-TH) + PREP, IAI with saline solution (IAI-SS) + PREP, and IAI with placebo + PREP. The IAIs were administered once, one week before starting PREP, which was performed twice weekly for 12 weeks. Outcomes assessed at baseline and at 2, 6, and 12 weeks post-IAI included pain (Numerical Pain Scale - NPS), swelling, function (Western Ontario and McMaster Universities Osteoarthritis Index - WOMAC), quality of life (Short Form-36 - SF-36), performance tests (Six-Minute Walk Test - 6MWT, Timed Up and Go Test - TUGT, Short Physical Performance Battery - SPPB), and muscle strength (one-repetition maximum test - 1RM). Due to the COVID-19 pandemic, only 15 participants per group completed the study protocol.

Results: All groups showed significant intragroup improvements over time in pain, function, muscle strength, and quality of life. However, no statistically significant differences were found between the groups for any of the assessed outcomes. The bodily pain domain of the SF-36 and analgesic consumption were the only measures showing differences over time.

Conclusion: The combination of IAI-TH and a 12-week PREP (twice weekly) was not superior to IAI-SS or placebo combined with the same PREP in improving pain, function, or quality of life in elderly patients with knee OA. These findings highlight the role of exercise as a key therapeutic strategy, regardless of prior IAI. Future studies with larger sample sizes and long-term follow-ups are needed to better assess the role of intra-articular corticosteroid injections in OA rehabilitation.

Clinical trial number: ensaiosclinicos.gov.br (RBR-556md5g). Registered 27 October 2022.