Advances in Rheumatology最新文献

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.

Background: Fibromyalgia (FM) is a musculoskeletal syndrome characterized by diffuse and chronic pain associated with other symptoms such as fatigue, sleep/cognition disorders, headache, depression and anxiety, resulting from a change in pain processing. Previous research has shown an increase in some interleukins (IL) in patients with FM when compared to controls, however, there is still no uniformity and consensus in the results. There is no study that evaluates IL8 mRNA expression in FM and its association with obesity and other clinical parameters. This study aims to verify the impact of IL8 mRNA expression on the clinical parameters of patients with FM (FMG) in relation to the comparison group (CG).

Method: This study evaluated patients diagnosed with FM treated at the rheumatology service of the Hospital das Clínicas of the Federal University of Pernambuco (HC-UFPE). The CG group was composed of individuals without chronic pain (companions of the patients and hospital employees). Clinical and demographic data were collected in both groups, and questionnaires for fatigue (FACIT-F), impact of FM (FIQ-R), depression (BDI), and sleep (NRS) were applied to both groups. Peripheral blood was collected for evaluation of IL8 gene expression through real time polymerase chain reaction (qPCR).

Results: Patients with FM show a lower frequency of IL8 gene expression compared to the CG, but FMG presented mainly up regulated in relation to CG. There was no association of IL8 expression and worse FIQ-R indices, sleep disturbance, BMI or fatigue. However, there was an association between IL8 expression and moderate depression (p = 0.002) and physical activity (p = 0.039), where patients in FMG who did express IL8 were practicing less physical activity.

Conclusion: Patients in FMG did not have a higher frequency of IL8 expression compared to CG, however patients with IL8 expression have a greater association with moderate depression.

Background: Although using Rituximab (RTX) and intravenous immunoglobulin (IVIg) alone or sequentially is a well-established treatment for several autoimmune diseases, the combination of these two forms of therapy is still rare, and its use is poorly studied.

Aim: To perform a systematic review on the use of RTX associated with IVIG in autoimmune conditions.

Methods: PubMed/MEDLINE, EMBASE, and Scielo databases were screened for articles on RTX plus IVIg in autoimmune diseases until May 2024.

Results: The review encompassed 21 studies evaluating RTX and IVIg for autoimmune diseases. Ten studies focused on pemphigus, involving 85 patients with diverse subtypes (47 pemphigus vulgaris, 27 pemphigoids, and 11 other variants). Most were case reports or series, with one retrospective study including controls. Positive outcomes were reported across all but one case of paraneoplastic pemphigus. Infections, such as P. jirovecii pneumonia, were noted in three studies, highlighting a potential risk. The other 11 studies involved 24 patients with conditions like polyneuropathies, lupus with CNS involvement, and neuromyelitis optica. While most reported favorable outcomes, one trial on IVIg-dependent polyneuropathies found RTX ineffective in reducing IVIg needs. Adverse events included pneumonia, venous thrombosis with pulmonary embolism, and infusion reactions, demonstrating the need for careful monitoring.

Conclusion: RTX plus IVIg seems to be an alternative option for the treatment of refractory autoimmune diseases. However, more studies with a larger number of participants and in different autoimmune diseases are desired.

Background: The risk of tuberculosis infection (TBI) and its progression to tuberculosis disease (TBD) among persons with immune-mediated inflammatory diseases (IMID) results from a complex interplay of patient and disease characteristics, immunosuppression level, and the epidemiological context. Brazilian recommendations are unclear about TBI screening and its preventive treatment (TPT) in persons with IMID.

Objective: To provide a comprehensive and evidence-based guideline for managing TBI in persons with IMID in Brazil.

Methods: This task force was constituded by 42 specialists with interest in IMID and TBD. A core leadership team (CLT) drafted fourteen clinical questions on the risk of tuberculosis and indications of TPT among persons with IMID who started, or are about to start immunosuppressive drugs. The CLT supervised the systematic reviews and formulated the recommendations. The experts voted using the Delphi Method.

Results: Nine recommendations were established. More than 80% of panelists voted "agree" and "strongly agree" with all statements. In brief, all persons with IMID starting or about to start immunosuppressive treatment should undergo tuberculin skin testing (TST) or interferon-gamma release assays (IGRAs), a chest imaging test and investigation of contact with active pulmonary or laryngeal TBD. TPT is mandatory for those with any positive result after excluding TBD. Exceptions include individuals with a history of TBD or a past positive TBI infection test. IGRA is preferred only in persons BCG-vaccinated in the past 2 years. Those with inconclusive IGRA results can have the test repeated once, and TPT should be offered if it remains indeterminate. TST or IGRA should be repeated yearly, for three years, when the previous test was negative, when starting or changing to a different class of immunosuppressive drug. Overall, the included studies had a low quality of evidence and high risk of bias.

Conclusions: These guidelines are meant to improve the management of TBI in IMID. Health professionals must consider the epidemiological risk, host features, the social scenario, the characteristics of the disease, the access to health resources, and the development of an individualized plan for every patient.

Background: Apitoxin^®, a drug based on bee venom was approved and released in Korea in 2003 as the ethical drug (ETC). It is well-known for its pain-relieving properties due to its potent anti-inflammatory effects. This raises the question of whether bee venom has benefits for other inflammatory disorders. Since its effectiveness in treating inflammation and pain associated with autoimmune diseases has been observed in several clinical cases in Korea, we conducted an efficacy study using an animal model of the systemic lupus erythematosus (SLE), an autoimmune disease with high medical unmet needs. In this research, we aim to confirm the potential therapeutic efficacy for SLE through the immunomodulation induced by bee venom.

Methods: MRL/FAS^lpr mice were injected subcutaneously with Apitoxin^® and evaluated for clinical parameters including proteinuria, skin lesions, and lymphadenopathy, flow cytometric evaluation of regulatory T cells (Treg), quantitative evaluation of anti-dsDNA antibody in serum by ELISA, and histomorphometric analysis of kidney tissues.

Results: Treatment with Apitoxin^® revealed a reduction in proteinuria, skin lesions, and lymphadenopathy in MRL/FAS^lpr mice. The percentage of CD3⁺CD4⁺CD25⁺FoxP3 (Treg) cells, which are associated with autoimmune diseases, was increased compared to the negative control (vehicle). Quantitative analysis of autoantibodies in the blood of MRL/FAS^lpr mice showed a decreasing tendency in the treatment groups with Apitoxin^®. Moreover, mesangial proliferation and inflammatory cell infiltration in glomeruli were significantly reduced in the treatment group with Apitoxin^®, which was associated with a statistically significant decrease in the amount of IgG infiltrated into the glomeruli.

Conclusion: Overall, the results confirmed that Apitoxin^® induced clinical improvement in SLE by increasing the proportion of Treg cells and decreasing anti-dsDNA antibodies in the blood, which resulted in therapeutic effects on glomerulonephritis associated with decreased renal infiltration of immune complexes.

Background: Numerous inflammatory complications related to COVID are described, including the Multisystem inflammatory Syndrome in Children (MIS-C) and Hyperinflammation. There is a scarcity of studies comparing these two groups.

Methods: Retrospective longitudinal outcome-conditioned study. Demographic, clinical, and laboratory variables are analyzed. Patients with history of COVID contact or infection with at least 24 h of fever, two or more systems involved and up to 21 years were included. Patients with no laboratory signal of inflammation or with other diagnoses for the condition were excluded. Demographic and laboratory data are presented as medians with interquartile ranges. Dichotomous variables and prevalences are reported as percentages. A ROC curve analysis was conducted to assess the discriminatory ability of these tests in relation to the MIS-C and hyperinflammation groups.

Results: We present fifty-four patients, thirty-one with MIS-C and twenty-three with hyperinflammation. The most frequent symptom in the MIS-C group was altered mental status in 61% vs. 46% (p = 0.014) and conjunctival hyperemia in 29% vs. 4% (p = 0.032). The most frequent laboratory findings were hypoalbuminemia in 68% vs. 26% (p = 0.002), increased serum troponin in 42% vs. 26% (p = 0.034), increased d-dimers in 94% vs. 76% (p = 0.015), as well as increased BNP in 55% vs. 17% (p = 0.02). On the other hand, the hyperinflammation group more frequently presented respiratory dysfunction in 57% vs. 13% (p = < 0.001) and serum ferritin equal or greater than 500 ng/mL in 94% vs. 77% (p = 0.046).

Conclusions: This is an original study comparing clinical and laboratory findings between MIS-C and hyperinflammation due to COVID. Altered mental status is more frequently associated with MIS-C while respiratory symptoms are associated with hyperinflammation. In addition, regarding laboratory tests, there is hypoalbuminemia, increase in serum troponin, BNP, and D-dimers specially in the MIS-C group and hyperferritinemia in the hyperinflammation group. Further studies are needed to assess the cutoff point of biological markers such as BNP, troponin, and d-dimers for diagnosis and/or prognosis in the pediatric population with MIS-C.

Background: The recurrent nature and prolonged course of ankylosing spondylitis (AS) impose substantial psychological disorders on patients. The aim of this study was to assess psychological disorders and analyze the overall risk of psychological disorders as well as the factors associated with depression, anxiety, and stress in ankylosing spondylitis.

Methods: Patients diagnosed with AS were selected from the China Rheumatoid Arthritis Registry of Patients with Chinese Medicine (CERTAIN) database for data analysis. General demographic characteristics and disease-related features of the patients were collected. The study analyzed clinical differences between patients with and without psychological disorders. Specific clinical characteristics of depression, anxiety, and stress were statistically analyzed. Clinical factors associated with overall psychological status and specific psychological disorders (depression, anxiety and stress) were analyzed by multivariate logistic regression.

Results: In our study cohort, 26.72% of AS patients were identified with psychological disorders, with 17.5% experiencing depression, 21.1% suffering from anxiety, and 7.9% reporting stress. We also observed significant overlaps among depression, anxiety, and stress in AS patients, with 53.47% experiencing multiple psychological disorders. Disease activity, health index, fatigue levels, and PGA were identified as significant factors associated with psychological disorders. Age, health index, fatigue levels, and PGA were the main influencing factors for depression; disease activity and PGA for anxiety; and disease activity, ASAS-HI, and fatigue for stress.

Conclusions: The study reveals a significant prevalence of psychological disorders among individuals with AS, which correlates closely with disease activity, health index, fatigue levels, and PGA. These findings highlight the imperative for assessment of psychological conditions into the comprehensive management approach for AS patients.